Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing

Abstract

BackgroundOne approach to prevent adverse drug events is to discontinue (“deprescribe”) medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient.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.

Deprescribing medications for older adults in the primary care context: A mixed studies review

“…Previous experiences of deprescribing varied, with 34% in a US study, 40% in a Canadian study, and 55% in an Australian study having experienced deprescribing. Knowledge of the process of deprescribing was limited, for example, with regard to tapering dosages or trialling deprescribing or with regard to the potential reduction in risks that deprescribing offers …”

“…Access to support alongside or within individual practice organisations may influence deprescribing. Changes in practice were suggested, including the ability to consult with pharmacists, inviting fellow GPs to conduct independent prescribing reviews, phone consults with geriatricians and/or specialists, and referrals to services able to provide nonpharmacological options . However, it is notable that the GPs in the study by Sinnige et al only sought help when their patient's condition did not improve.…”

“…Delegation of tasks to other team members was mentioned, such as medication reconciliation to nurses or follow‐up to pharmacists . In practice, this may not happen, as some GPs were uncomfortable with delegation, fearing it would undermine their accountability and authority as a prescriber …”

“…This may result from patients not communicating important information regarding their medications . Furthermore, other prescribers, such as medical specialists, may not effectively communicate all their treatment plans (eg, medication indications and/or duration of treatment) to the GP …”

Advancing the Science of Deprescribing: A Novel Comprehensive Conceptual Framework

“…Rational decision making is based on prescriber explicit knowledge, beliefs, skills, and preferences. 30,36 Behavioral factors include prescriber decision tendencies (eg, heuristics, biases) that reflect tacit knowledge. 37 Behavioral factors influencing prescriber behavior are rarely, if ever, explicitly included in any existing frameworks, except "inertia" in the earlier Anderson framework.…”