Deprescribing medications: Do out‐of‐pocket costs have a role?

Hung, Anna; Sloan, Caroline E.; Boyd, Cynthia M.; Bayliss, Elizabeth A.; Hastings, Susan; Maciejewski, Matthew L.

doi:10.1111/jgs.17974

Cited by 3 publications

(5 citation statements)

References 17 publications

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“…Our finding that physicians consider the financial impact of continuing or discontinuing a medicine as the least important barrier to deprescribing may provide an alternative entry point to starting conversations about deprescribing with their patients and may require clinician education. As highlighted by Hung et al, deprescribing conversations might start with discussing medications that risk an ADE or medications with no evidence of benefit, but patients may also wish to address prescription costs and medication burden. Up to 68% of patients report that they spend a lot of money on their medications or that having to pay less for medicines would play a role in their willingness to deprescribe .…”

Section: Discussionmentioning

confidence: 99%

“…Further, these ethical dilemmas related to optimal prescribing arise ubiquitously for clinicians treating people living with dementia who are particularly vulnerable to serious harm from polypharmacy (adverse drug events or drug interactions), treatment burden, and cognitive changes from adverse effects. [5][6][7][8][9] The clinical management decisions for this population require ethically nuanced and pragmatic shared decision-making aligned with the patient's goals of care, which can be further complicated by how to best respect patient autonomy in the context of impaired decisionmaking and how to consider benefits and risks to caregivers' well-being stemming from managing symptoms for patients. 10 Clinicians have little evidence to guide deprescribing decisions due to a clinical research culture focused on generating evidence to inform treatment intensification and methodologic limitations to conducting deprescribing investigations at scale.…”

Section: Introductionmentioning

confidence: 99%

“…As highlighted by Hung et al, 7 deprescribing conversations might start with discussing medications that risk an ADE or medications with no evidence of benefit, but patients may also wish to address prescription costs and medication burden. Up to 68% of patients report that they spend a lot of money on their medications or that having to pay less for medicines would play a role in their willingness to deprescribe.…”

mentioning

confidence: 99%

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Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Norton,

Zeng,

Bayliss

et al. 2023

JAMA Netw Open

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ImportancePhysicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population.ObjectiveTo understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions.Design, Setting, and ParticipantsA cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021.Main Outcomes and MeasuresThe study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing.ResultsA total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice).Conclusions and RelevanceFindings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Norton,

Zeng,

Bayliss

et al. 2023

JAMA Netw Open

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“…One of these measures, for example, “Concurrent Use of Opioids and Benzodiazepines,” assesses the percentage of insured adults who have had concurrent prescriptions for opioids and benzodiazepines for ≥30 cumulative days, excluding patients who have cancer, sickle cell disease, or are in hospice 5 . This measure seeks to address evidence that when opioids and benzodiazepines are used concurrently, they increase the risk of overdose, hospitalizations, and death 6–9 . Overdose mortality rates among concurrent users of opioids and benzodiazepines are estimated to be 10 times compared with opioid‐only users 10 .…”

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confidence: 99%

“…5 This measure seeks to address evidence that when opioids and benzodiazepines are used concurrently, they increase the risk of overdose, hospitalizations, and death. [6][7][8][9] Overdose mortality rates among concurrent users of opioids and benzodiazepines are estimated to be 10 times compared with opioid-only users. 10 About 3% of older adults have concurrent prescriptions for opioids and benzodiazepines.…”

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confidence: 99%

Considering pharmacoequity when deprescribing potentially inappropriate medications

Sloan

Hung

2023

J American Geriatrics Society

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Every 3 years, the American Geriatrics Society updates its Beers Criteria, a list of medications that are potentially inappropriate to prescribe to older adults. The list includes medications that can be harmful to older adults and medications that interact with other medications and/or common comorbidities in this population. 1 The use of potentially inappropriate medications (PIMs) is associated with an increased risk of falls, cognitive decline, frailty, hospitalizations, and mortality. 2-4 Examples of PIMs include anticholinergics, antipsychotics, benzodiazepines, and opioids. Despite widespread familiarity with the Beers This editorial comments on the article by Niznik et al. in this issue.

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Assessing causality in deprescribing studies: A focus on adverse drug events and adverse drug withdrawal events

Li,

Bayliss,

Brookhart

et al. 2024

J American Geriatrics Society

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Generating real‐world evidence about the effect of medication discontinuation or dose reduction on outcomes, such as reduction of adverse drug effects (ADE; intended benefit) and occurrence of adverse drug withdrawal events (ADWE; unintended harm), is crucial to informing deprescribing decisions. Determining the causal effects of deprescribing is difficult for many reasons, including lack of randomization in real‐world study designs and other design and measurement issues that pose threats to internal validity. The inherent challenge is how to identify the effects, both intended benefits and unintended harms, of a new medication stoppage or reduction when implemented in patients with many potential clinical and social risks that may influence the likelihood of deprescribing as well as outcomes. We discuss methodological issues of estimating the effect of medication discontinuation or reduction on risk of ADEs and ADWEs considering: (1) sampling study populations of sufficient size with the potential to demonstrate clinically meaningful and quantifiable outcomes, (2) accurate and appropriately timed measurement of covariates, outcomes, and discontinuation, and (3) statistical approaches to managing confounding and other biases inherent in long‐term medication use by individuals with multiple morbidities. Designing rigorous deprescribing studies that address internal validity threats will support evidence generation by improving the ability to assess benefits and harms when the exposure of interest is the absence of a medication. Iterative learnings about data quality, variable definition, variable measurement, and exposure‐outcome associations will inform strategies to improve the causal inferences possible in real‐world deprescribing studies.

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Deprescribing medications: Do out‐of‐pocket costs have a role?

Cited by 3 publications

References 17 publications

Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Considering pharmacoequity when deprescribing potentially inappropriate medications

Assessing causality in deprescribing studies: A focus on adverse drug events and adverse drug withdrawal events

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