Patient perceptions of proactive medication discontinuation

Linsky, Amy; Simon, Steven R.; Bokhour, Barbara G.

doi:10.1016/j.pec.2014.11.010

Cited by 90 publications

(155 citation statements)

References 25 publications

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“…22 Substantial evidence shows that older people's attitudes can be internally contradictory: they may be positive about both taking their medicines [24][25][26] and taking fewer medicines. 27 Older people's willingness to either tolerate polypharmacy or discontinue a medicine seems to be influenced by the communication skills 24 27 and perceived experience of the clinician, 28 and the degree to which the older person trusts them. 24 Experiencing adverse effects may increase openness to deprescribing.…”

Section: Older People's Attitudes Towards Medicinementioning

confidence: 99%

“…27 Qualitative research suggests that deprescribing in primary care can be hampered by lack of communication and cooperation with prescribing specialists, [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] and that older patients worry about poor communication about prescribing between clinicians. 24 Research on interdisciplinary shared decision making is still limited, 36 and the role of different types of clinician is likely to vary depending on the context.…”

Section: Multidisciplinary Decisions and Companion Involvementmentioning

confidence: 99%

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Too much medicine in older people? Deprescribing through shared decision making

Jansen

Naganathan

Carter

et al. 2016

BMJ

232

233

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Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults Too much medicine is an increasingly recognised problem, 1 2 and one manifestation is inappropriate polypharmacy in older people. Polypharmacy is usually defined as taking more than five regular prescribed medicines.3 It can be appropriate (when potential benefits outweigh potential harms) 4 but increases the risk of older people experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission. [5][6][7] There is limited evidence to inform polypharmacy in older people, especially those with multimorbidity, cognitive impairment, or frailty.8 Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life. [9][10][11] Two recent reviews of the literature on deprescribing stressed the importance of patient involvement and shared decision making.12 13 Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms.14 When they engage in shared decision making they become better informed about potential outcomes and as a result patients tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing. 15 However, shared decision making in this context is not easy, and there is little guidance on how to do it. 16 We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions; identify challenges for older adults, their companions, and clinicians (figure); give practical advice on how challenges may be overcome; highlight where more work is needed; and identify priorities for future research (table). 17 18 Process for deprescribing with older adultsStep 1: creating awareness that options existThe clinician and patient acknowledge that a decision can be made about continuation or discontinuation of medicines, and that this requires input from both clinician and patient. When to initiate discussions about deprescribingPrescribing new medicines is often straightforward, driven by a new diagnosis, symptom, or test result. When to consider ceasing medicines is less clear.12 Possible triggers include the number of medicines taken (perhaps ≥10); a new symptom that may be an adverse effect of a medicine; identifying high risk, ineffective, or unnecessary medicines; apparent non-adherence; or changed treatment priorities. 19 Most of these situations can be identified only by a medicines review. Reviews can be triggered by important life transitions (such as hospital admission, a new diagnosis, or seeing a new doctor) and can be initiated by the clinician or patient, but they are often Older people's attitudes towards medicineClinicians may be reluctant to initiate discussions about deprescribing with older people, believing tha...

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Section: Older People's Attitudes Towards Medicinementioning

confidence: 99%

Section: Multidisciplinary Decisions and Companion Involvementmentioning

confidence: 99%

Too much medicine in older people? Deprescribing through shared decision making

Jansen

Naganathan

Carter

et al. 2016

BMJ

232

233

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show abstract

“…Moen et al 27 conducted a focus group study with older adults in Sweden to assess their attitudes towards taking multiple medications and Linsky et al 30 conducted a qualitative study of US veterans in relation to their perception of proactive medication cessation. Both of these studies found that the relationship with their doctor had an influence on their attitudes to medications and willingness to withdraw one or more of them.…”

Section: Comparison With Existing Literaturementioning

confidence: 99%

Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study

Reeve¹,

2016

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“…However, clinicians also discussed the many factors that impede their ability to deprescribe, including patient complexity, clinical uncertainty, and shared management with other healthcare providers, all of which can contribute to “clinical inertia” around medication discontinuation [10, 11]. …”

Section: Introductionmentioning

confidence: 99%

Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing

Linsky

Meterko

Stolzmann

et al. 2017

BMC Health Serv Res

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BackgroundOne approach to prevent adverse drug events is to discontinue (“deprescribe”) medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. However, there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice. We sought to determine clinical prescribers’ preferences for interventions that would improve their ability to appropriately and proactively discontinue medications.MethodsWe conducted a national web-based survey of 2475 prescribers [physicians, nurse practitioners (NP), physician assistants (PA), and clinical pharmacy specialists] practicing in US Veterans Affairs (VA) primary care clinics. One survey question presented 15 potential changes to medication-related practices and respondents ranked their top three choices for changes that would “most improve [their] ability to discontinue medications.” We summed the weighted rankings for each of the 15 response options. Preferences were determined for the whole sample and within subgroups of respondents defined by demographic and background characteristics, medication-relevant experience, and beliefs.ResultsAmong the 326 respondents who provided rankings, the top choice for a change that would help improve their ability to discontinue medications was “Requiring all medication prescriptions to have an associated ‘indication for use.’” This preference was followed by “Assistance with follow-up of patients as they taper or discontinue medications is performed by another member of the Patient Aligned Care Team (PACT)” and “Increased patient involvement in prescribing decisions.” This combination of options, albeit in varying rank order, was the most commonly selected, with 250 respondents (77%) who answered the question including at least one of these items in their three highest ranked choices, regardless of their demographics, experience, or beliefs.ConclusionsContinued efforts to improve clinicians’ ability to make prescribing decisions, especially around deprescribing, have many potential benefits, including decreased pharmaceutical and health care costs, fewer adverse drug events and complications, and improved patient involvement and satisfaction with their care. Future work, whether as research or quality improvement, should incorporate clinicians’ preferences for interventions, as greater buy-in from front-line staff leads to better adoption of changes.

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Patient perceptions of proactive medication discontinuation

Cited by 90 publications

References 25 publications

Too much medicine in older people? Deprescribing through shared decision making

Too much medicine in older people? Deprescribing through shared decision making

Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study

Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing

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