Patient and provider perspectives on the development and resolution of prescribing cascades: a qualitative study

Abstract

Background Prescribing cascades occur when the side effect of a medication is treated with a second medication. The aim of the study was to understand how prescribing cascades develop and persist and to identify strategies for their identification, prevention and management. Method This qualitative study employed semi-structured interviews to explore the existence of prescribing cascades and to gather patients', caregivers' and clinicians’ perspectives about how prescribing cascades start, persist and how they might be resolved. Participants were older adults (over age 65) at an outpatient Geriatric Day Hospital (GDH) with possible prescribing cascades (identified by a GDH team member), their caregivers, and healthcare providers. Data were analyzed using an inductive content analysis approach. Results Fourteen participants were interviewed (eight patients, one family caregiver, one GDH pharmacist, three GDH physicians and one family physician) providing a total of 22 interviews about patient-specific cases. The complexity and contextually situated nature of prescribing cascades created challenges for all of those involved with their identification. Three themes impacted how prescribing cascades developed and persisted: varying awareness of medications and cascades; varying feelings of accountability for making decisions about medication-related care; and accessibility to an ideal environment and relevant information. Actions to prevent, identify or resolve cascades were suggested. Conclusion Patients and healthcare providers struggled to recognize prescribing cascades and identify when they had occurred; knowledge gaps contributed to this challenge and led to inaction. Strategies that equip patients and clinicians with resources to recognize prescribing cascades and environmental and social supports that would help with their identification are needed. Current conceptualizations of cascades warrant additional refinement by considering the nuances our work raises regarding their appropriateness and directionality.

“Kind of blurry”: Deciphering clues to prevent, investigate and manage prescribing cascades

“…When we began to study this phenomenon, consistent with existing literature [ 1 , 9 ], we conceptualized addressing prescribing cascades as linear, discrete steps: identify, resolve, prevent. In our prior study with patients from the GDH program, we found that prescribing cascades were complex and contextually situated [ 19 ]. Prescribing cascades were difficult to identify and their development was impacted by varying levels of awareness of medications, their side effects and related cascades [ 19 ].…”

“…In our prior study with patients from the GDH program, we found that prescribing cascades were complex and contextually situated [ 19 ]. Prescribing cascades were difficult to identify and their development was impacted by varying levels of awareness of medications, their side effects and related cascades [ 19 ]. In this study, our findings further reinforce that a simple model involving a linear process does not adequately capture the nuances of the therapeutic challenges of prescribing cascades.…”

“…Only the participant and interviewer were present; there were no repeat interviews. Interview guides (patient, caregiver, healthcare provider versions, S2 Appendix ) adapted from the pilot interviews [ 19 ], focused on factors associated with the development, identification and resolution of their suspected prescribing cascade(s); the resulting clinical impact; and participant insights regarding potential interventions to prevent, identify or resolve prescribing cascades. Interviewers completed memos following each interview detailing overall impressions and recommendations for questions of the other interviewees involved in the case.…”

“…In a previous study, we interviewed older adults attending a Geriatric Day Hospital program (i.e., a referral-based ambulatory clinic with an interprofessional care team) who may have experienced one or more prescribing cascades and their healthcare providers to understand how cascades develop and how they are resolved [ 19 ]. We found that prescribing cascades were difficult to identify and that their development was impacted by varying levels of awareness of medications, their side effects and related cascades, patients struggling to report their medication experiences, and of personal accountability regarding decisions about medication changes.…”

A Prescribing Cascade of Proton Pump Inhibitors Following Anticholinergic Medications in Older Adults With Dementia

“…How to address this prescribing cascade or others like it and reduce its risk of occurrence will also take effort from prescribers and collaboration from all members of the healthcare team. An Ontario-based qualitative study investigated the patient and provider perspectives on prescribing cascades in community-dwelling adults aged 65 and older ( Farrell et al, 2020 ). Using semi-structured interviews with patients, pharmacists, and physicians evolving themes were identified in consideration of best ways to resolve prescribing cascades.…”