Prescriber perspectives on low‐value prescribing: A qualitative study

Abstract

Background Health systems are increasingly implementing interventions to reduce older patients' use of low‐value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low‐value prescribing are poorly understood. Objective To identify the characteristics that affect the value of a medication and those factors influencing low‐value prescribing from the perspective of primary care physicians. Design Qualitative study using semi‐structured interviews. Setting Academic and community primary care practices within University of Pittsburgh Medical Center health system. Participants Sixteen primary care physicians. Measurements We elicited 16 prescribers' perspectives on definitions and examples of low‐value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low‐value prescribing. Results We identified three key themes. First, prescribers viewed low‐value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low‐value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low‐value prescribing a default practice pattern. Third, interventions addressing low‐value prescribing must minimize the cognitive load and time pressures that make low‐value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. Conclusions Our findings demonstrate that low‐value prescribing is a well‐recognized phenomenon, and that interventions to reduce low‐value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low‐value prescribing a default practice.

Primary care physicians’ approaches to low-value prescribing in older adults: a qualitative study

“…When presented with clinical scenarios outside of the constraints of real-life clinical encounters, physicians in our cohort generally adhered to medication safety and deprescribing guidelines [22][23][24][25][26][27]. In a prior study examining PCPs' broad views on medication value, incentives to participate in or reduce low-value prescribing and the acceptability of system-level interventions to reduce lowvalue prescribing, we demonstrated that while PCPs wish to avoid LVP, they find it difficult to address in real life practice due to a variety of factors, including perceived patient expectations, deference to subspecialists, time constraints and misaligned quality metrics and incentives [14]. This suggests that ongoing use of low-value medications and polypharmacy is driven by these perceived barriers, rather than a lack of knowledge about potentially LVP in older adults.…”

“…Two clinical scenarios involving potential LVP were presented as part of a semi-structured interview. The clinical scenarios were discussed for approximately 10-15 minutes during the 30-40 minutes semi-structured interviews which also addressed PCPs' broad views on medication value, incentives to participate in or reduce low-value prescribing and the acceptability of system-level interventions to reduce low-value prescribing, the results of which are presented elsewhere [14]. We chose to analyze and present the PCP responses to clinical scenarios separately in order to specifically identify themes related to how PCPs approach LVP during patient encounters rather than combining these themes with more generalized views on medication value and LVP.…”

Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults

“…For this step, we synthesized the preexisting recommendations from the Choosing Wisely campaign and other medication safety criteria (eg, the Beers Criteria), peerreviewed literature, and the results of 3 qualitative studies on low-value prescribing. [11][12][13] Second, using an online modified-Delphi approach, we convened a panel of physicians and pharmacists to codify the final components of EVOLV-Rx (Figure 1). Members of this panel serve as health system leaders, practicing clinicians, and researchers.…”

“…19 We integrated the findings from 3 qualitative studies (which were conducted by some of us and other members of our research team), which used focus groups with patients and caregivers as well as semistructured interviews with primary care physicians to characterize their perspectives on and specific examples of low-value prescribing (eTable 1 in the Supplement). [11][12][13] To focus on those candidate low-value prescribing practices that were current and had the potential to affect the greatest number of older adults, we narrowed down our initial collection of low-value prescribing recommendations to those that overlapped with the 100 most frequently prescribed or costly medications among Medicare beneficiaries in fiscal year 2017 (the most recent year of available data at the beginning of this study). We also included medications whose frequency of use was comparable to drugs that were most frequently prescribed in Medicare Part D but may be purchased over the counter, such as aspirin or docusate sodium.…”

Re: Negative treatments… changing our words to drive deprescribing

“…However, we respectfully favor the term lowvalue prescribing in the context of our paper, as we feel it more adequately reflects the broad tradeoffs between the costs and harms versus the potential benefits that clinicians must consider when prescribing medications to older adults. 4 For example, the use of a low-value medication may afford a patient some benefits, even though those benefits are balanced by the potential risks or excess costs. If a patient and the prescribing clinician arrived a mutual understanding to use this medication aware of the tradeoffs, then I would not consider this a negative treatment.…”