Understanding Stakeholder Views Regarding the Design of an Intervention Trial to Reduce Anticholinergic Burden: A Qualitative Study

Abstract

Background: Anticholinergic burden (ACB), is defined as the cumulative effect of anticholinergic medication which are widely prescribed to older adults despite increasing ACB being associated with adverse effects such as: falls, dementia and increased mortality. This research explores the views of health care professionals (HCPs) and patients on a planned trial to reduce ACB by stopping or switching anticholinergic medications. The objectives were to explore the views of key stakeholders (patients, the public, and HCPs) regarding the potential acceptability, design and conduct of an ACB reduction trial.Materials and Methods: We conducted qualitative interviews and focus groups with 25 HCPs involved in prescribing medication with anticholinergic properties and with 22 members of the public and patients who were prescribed with the medication. Topic guides for the interviews and focus groups explored aspects of feasibility including: 1) views of a trial of de-prescribing/medication switching; 2) how to best communicate information about such a trial; 3) views on who would be best placed and preferred to undertake such medication changes, e.g., pharmacists or General Practitioners (GPs)? 4) perceived barriers and facilitators to trial participation and the smooth conduct of such a trial; 5) HCP views on the future implementability of this approach to reducing ACB and 6) patients’ willingness to be contacted for participation in a future trial. Qualitative data analysis was underpinned by Normalization Process Theory.Results: The public, patients and HCPs were supportive of an ACB reduction trial. There was consensus among the different groups that key points to consider with such a trial included: 1) ensuring patient engagement throughout to enable concerns/potential pitfalls to be addressed from the beginning; 2) ensuring clear communication to minimise potential misconceptions about the reasons for ACB reduction; and 3) provision of access to a point of contact for patients throughout the life of a trial to address concerns; The HCPs in particular suggested two more key points: 4) minimise the workload implications of any trial; and 5) pharmacists may be best placed to carry out ACB reviews, though overall responsibility for patient medication should remain with GPs.Conclusion: Patients, the public and HCPs are supportive of trials to reduce ACB. Good communication and patient engagement during design and delivery of a trial are essential as well as safety netting and minimising workload.

A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records

“…Factors that may have impacted actual uptake of recommendations firstly include the COVID‐19 outbreak during this study, resulting in significant hospital staffing and rostering changes, limiting time for deprescribing interventions 29,45 . Other possible factors included existing relationship between the medical registrar and the steward, patient, carer or GP's openness to deprescribing and time of deprescribing discussion between the steward and registrar, with early contact in the patient journey allowing registrars more time to action medication changes 29,45 . Future studies should not only identify enablers and barriers to deprescribing from the perspective of key stakeholders such as patients, clinicians, policymakers and researchers, but should additionally focus on identifying practical solutions to address identified barriers as per local workflow, through the process of local co‐design, to maximise impact and sustainability of deprescribing interventions 29,45 .…”

“…Whilst the medical team agreed with the majority of the steward's recommendations, these recommendations were not always actioned. Factors that may have impacted actual uptake of recommendations firstly include the COVID‐19 outbreak during this study, resulting in significant hospital staffing and rostering changes, limiting time for deprescribing interventions 29,45 . Other possible factors included existing relationship between the medical registrar and the steward, patient, carer or GP's openness to deprescribing and time of deprescribing discussion between the steward and registrar, with early contact in the patient journey allowing registrars more time to action medication changes 29,45 .…”

“…[26][27][28][29] CDSS may be more clinically meaningful and have higher uptake when the signals generated by the CDSS are translated to individual patients by a group of clinicians or a dedicated clinician, such as a steward. 20,29,30 Therefore, we developed an intervention bundle incorporating the DBI in routinely used electronic medical records (eMR). We implemented a stewardship program providing individualised patient advice using our intervention bundle to facilitate deprescribing of anticholinergic and sedative medications.…”

“…Computerised decision support systems (CDSS) can incorporate risk assessment tools in routine care and guide decision making during medication review, improve communication about medicines between clinicians and patients and facilitate deprescribing. [26][27][28][29] CDSS may be more clinically meaningful and have higher uptake when the signals generated by the CDSS are translated to individual patients by a group of clinicians or a dedicated clinician, such as a steward. 20,29,30 Therefore, we developed an intervention bundle incorporating the DBI in routinely used electronic medical records (eMR).…”

“… 26 , 27 , 28 , 29 CDSS may be more clinically meaningful and have higher uptake when the signals generated by the CDSS are translated to individual patients by a group of clinicians or a dedicated clinician, such as a steward. 20 , 29 , 30 …”