Article Figures & Data
Tables
Characteristic Number Sex Women 10 Men 14 Years in practice More than 20 12 10–20 6 Less than 10 6 Employment status Partner 11 Long-term locum 10 Locum 2 Trainee (3rd year) 1 Practice location Urban 13 Suburban 1 Rural 10 Practice size Small 7 Medium 7 Large 10 - Table 2
Primary Care Physicians’ Views on the Barriers to and Facilitators of Deprescribing in Everyday Practice
Barriers and Facilitators Example Quotations Sociocultural factors Patient expectations I think there seems to be an expectation that if they’ve got a problem they’ll be given another pill to fix it. (GP-9)
There are people who see medication as the barrier between them and the grave. (GP-7)Medical culture of prescribing I guess it’s easy to keep adding in medications without looking at whether they need all the medications they’re already on. (GP-21)
Prescribing is something that’s taught a lot, you know. Deprescribing isn’t really something that’s been talked about from the get-go. It’s not something that’s come up. As a GP trainee, it’s not something that we’ve had a session on. (GP-9)Personal and relational factors Uncertainty We all want to do the right thing, but… We don’t know what the combinations of many conditions and all the medications for each of their conditions, what kind of extra risk that poses. (GP-8) Fear of damage to reputation, accountability for adverse outcomes, moral blame and shame You could be viewed as being neglectful, as being a bad doctor, as being not competent, if you’re taking medications away and someone has an event. (GP-5)
We end up putting people on more stuff than I’m really comfortable with, but it’s hard to defend not complying with the guidelines. (GP-15)
If [the patient] had a heart attack and the doctor in the hospital said “Oh it’s because your [doctor] stopped your statin,” then [the doctor] would feel terrible, and so he doesn’t stop them even though he thinks he should. (GP-2)
The risk that you take on yourself…if the person, say, has a heart attack and you stopped their statin. So, there’s that psychological stuff that goes on. (GP-5)Research, education and training I think we need more research, more collaborations. (GP-3)
I think education would be very helpful for us, in sort of just giving us more confidence. (GP-17)Maintaining relationships with patients and colleagues It can come off looking like you no longer care about the patient, you know, “You’re old enough to die now so it doesn’t really matter.” (GP-14)
Sometimes people will say, “Why shouldn’t I have the same treatment that a younger person would have? You’re just writing me off.” (GP-16)
It’s quite difficult to say, “How about we reduce [a medicine]?” when it’s only just been started by somebody else, like a hospital doctor or something. (GP-6)
The reason you don’t stop things is you think they [specialists] know better than you. (GP-2)Ethical duty: beneficence I think you’ve got to do what’s right for your patient, regardless. (GP-13) Organizational factors Fast pace and competing demands of practice There is no time … [You’ve got] complicated, complex patients and you never have more than 15 minutes and sometimes its double booked. There’s never time to spend on this. (GP-2)
Patients are not coming in for a deprescribing conversation; they’re coming in for something else like a repeat or to talk about their aching joints. So the deprescribing conversation is an added thing to the consultation. (GP-5)
A lot of the time the opportunities for deprescribing are lost by either repeat prescription generation without seeing the patient or doing their repeat medications in an appointment where they’ve come in to talk about something else. (GP-9)
With the best will in the world we get really busy, we get distracted and we mean to do things that we don’t do. (GP-3)Targeted funding You need some funded time with the patient so that you can bring the patient in and say “This is a special appointment that’s not to talk about your current medical problems, it’s specifically about managing your medicines better.” (GP-4) Computer prompts and alerts An alert would give you a little bit of courage to do it, or give you more reassurance, or give you a way to bring it up with the patient like, “Look, you see, the computer has noticed you’re on too many medications, maybe we can reduce it.” (GP-2)
Memory support… Prompts are good, helpful. (GP-3)Fragmentation of care As a locum, it’s difficult because you don’t know the indications, you don’t know the patient very well, you don’t know the history. Has someone tried to stop them before and it hasn’t gone well and had to be restarted? (GP-2)
[Deprescribing is difficult] if they don’t know me well, haven’t built up that trust. (GP-12)Information flow between prescribers The electronic portals might be something that will make it easier in the future, centralized storage of information that everyone can access. (GP-9) Access to expert advice and user-friendly decision support I like to ring someone up and just ask them what I should do. I would like to be able to ring a cardiologist or geriatrician. I often email a pharmacist. (GP-2)
I’ve recently come across an app, which I have on my iPad [MedStopper], and you can put in the medication list there and it will prioritize them for you. So, that’s a really neat little tool. (GP-11)Guidelines Most guidelines are suggesting you add medicines rather than take them away. (GP-7)
In each guideline for each condition, have a section on when it would be appropriate to reduce or stop each medication. (GP-2)
I think we need multi-morbidity guidelines, the commonest multi-morbidities like chronic pain from arthritis and heart failure and diabetes together. (GP-8)Communication of risk They’re used to being on these medications; whatever they’re feeling in their lives and the way that they’re experiencing their lives, this is their usual way of feeling and they’re used to it. You think that perhaps taking off the statin will make them feel better, but that’s a very subtle thing to try and tell them because most of the time they’re not actually feeling bad, or they don’t know they’re feeling bad. (GP-1)
Communicating risk to patients, it’s very difficult. (GP-14)Access to non-pharmaceutical options It’s harder to access other services. Non-pharmaceutical options are often a lot harder to access than medications. (GP-9) Patient activation A recall that sends out something to the patient every year and says, “Next time you’re at the doctor make sure to look over the pills.” (GP-8)
[A letter] to warm the patient up … (GP-3)
Additional Files
Supplemental Appendix
Supplemental Appendix
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file
The Article in Brief
Swimming Against the Tide: Primary Care Physicians� Views on Deprescribing In Everyday Practice
Katharine A. Wallis , and colleagues
Background Safe prescribing entails regular medicines review, initiating medicines that are indicated and deprescribing (tapering and withdrawing medicines) when the risks outweigh the potential benefits. This qualitative study of 24 primary care physicians in Auckland, New Zealand explores the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice.
What This Study Found Although deprescribing is essential to best prescribing practices, it runs counter to patient expectations, medical culture, and organizational factors. Participants recognized the importance of deprescribing for older patients, while identifying many barriers and few incentives to the practice. Less experienced physicians and those in short-term low-trust therapeutic relationships reported finding deprescribing challenging.
Implications
- The authors state that interventions to support safer prescribing should consider sociocultural influences, the importance to physicians of maintaining relationships, the sense of vulnerability many physicians feel in practice, and the organizational constraints they face.
Annals Journal Club
July/Aug 2017: Is Deprescribing Swimming Against the Tide?
The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to thinking critically about important issues affecting primary care and act on those discussions.1
JOIN US FOR TWITTER JOURNAL CLUB
July 30, 2017, 7:00 pm EDT/11pm GMT, @AnnFamMed or #AJC. This moderated chat will pose questions about the article at regular intervals.
HOW IT WORKS
In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion/ Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
Wallis KA, Andrews A, Henderson M. Swimming against the tide: primary care physicians' views on deprescribing in everyday practice. Ann Fam Med 2017;15(4):341-346.
Discussion Tips
Deprescribing, the practice of tapering and discontinuing unnecessary medications, is a task that often falls to primary care physicians. This study uses qualitative research methods to explore physicians' views on deprescribing in elderly patients, a population especially at risk for polypharmacy. The article provides an opportunity to discuss the art of deprescribing and to initiate a conversation about personal, cultural, and organizational barriers to this important component of patient safety.
Discussion Questions
- What question is asked by this study and why does it matter?
- How does this study advance beyond previous research and clinical practice on this topic?
- How strong is the study design for answering the question?
- To what degree can the findings be accounted for by the following:
- How participating physicians were selected? (Did the authors achieve saturation? That is, did they sample until the point at which no new information was obtained from further sampling?)
- How the data were collected?
- Risk of bias using the snowball technique?
- Chance?
- How the findings were analyzed and interpreted?
- What are the main study findings?
- What barriers to deprescribing can you identify in your practice? What incentives can you identify?
- How comparable is the study sample to your practice? What is your judgment about the transferability of findings to your setting?
- What contextual factors are important for interpreting the findings?
- How might this study change your practice? Policy? Education? Research?
- Who are the constituencies for the findings, and how they might be engaged in interpreting or using the findings?
- What are the next steps in interpreting or applying the findings?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3 /196.full.
In this issue
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- Challenges and barriers to physician decision-making for prescribing and deprescribing among patients with multimorbidity in eastern Chinas primary care settings: a qualitative study
- Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review
- Sleep disturbance in people living with dementia or mild cognitive impairment: a realist review of general practice
- Barriers and facilitators of successful deprescribing as described by older patients living with frailty, their informal carers and clinicians: a qualitative interview study
- Safer Prescribing and Care for the Elderly (SPACE): a cluster randomised controlled trial in general practice
- Factors associated with potentially inappropriate prescriptions and barriers to medicines optimisation among older adults in primary care settings: a systematic review
- Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review
- Low-Dose Aspirin Use Among African American Older Adults
- Barriers and facilitators to deprescribing in primary care: a systematic review
- Safer Prescribing and Care for the Elderly (SPACE): a pilot study in general practice
- In This Issue: Trends, Prescribing, Deprescribing