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

Abstract

Background Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians’ baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians’ (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios. Methods As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients’ expectations surrounding low-value prescribing. Results We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients’ well-being over satisfying their expectations. Conclusions When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

“…Several of these barriers and facilitators, such as the clinicians’ move away from harmful care and their fear of missing a diagnosis, could be connected to the clinicians’ motivation to provide the best care for their patients. Two recent studies confirm the importance of harm reduction as a motivator 12 28. Another connecting theme seems to be the effort that goes into providing less care and communicating this with patients.…”

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.…”