RE: Proactive Deprescribing Among Older Adults With Polypharmacy

Dear Editor,
We read with great interest the recent qualitative study by Ie et al. exploring patients' perspectives on proactive deprescribing using a deductive-inductive approach (1). We agree with the authors' emphasis on the importance of patient engagement in the deprescribing process. To enrich future research on polypharmacy, we would like to offer a perspective on polydoctoring as an important related aspect.
Polydoctoring is reportedly a significant issue within healthcare systems offering free access, such as in Japan (2). This means patients can freely visit multiple clinics, with prescriptions often managed independently by each doctor. Existing evidence suggests that polydoctoring correlates with polypharmacy, fragmentation of care, and increased medical costs (3). Furthermore, other evidence indicates that the number of prescribers is an independent risk factor for adverse drug events (ADEs) (4). In the context of polypharmacy, potentially inappropriate medications (PIMs) might be prescribed due to factors such as miscommunication among various prescribers or a lack of complete awareness of the patient’s drug profile by individual doctors, potentially leading to ADEs.
We propose that polydoctoring could negatively impact patients' motivation or proactive engagement in deprescribing, key themes explored by the authors. While the authors effectively captured patient perspectives through detailed semi-structured interviews and qualitative analysis, understanding the complexity introduced by multiple prescribers—for example, knowing 'how many prescriptions are from how many different doctors?'—is an important consideration for strategies aimed at reducing PIMs. For instance, polypharmacy due to several physicians might overwhelm patients or make them hesitant to initiate deprescribing discussions, potentially aligning them with the 'indifferent' or 'fearful but passive' typologies identified in their study. Therefore, incorporating an analysis of prescribing sources (i.e., the number of prescribers) could offer deeper insights into the barriers patients face and further contextualize the study's findings on patient proactiveness.
In conclusion, while not the direct focus of Ie et al.'s study, the phenomenon of polydoctoring presents a significant challenge to resolving polypharmacy and may influence the patient proactiveness highlighted in their research. Measuring the number of prescribers as a clinical characteristic is important for future research on polypharmacy. We thank the authors for their excellent work and valuable contribution to the research field of polypharmacy (1,2,5), and we appreciate the opportunity to comment.

References
1. Ie K, Machino R, Albert SM, et al. Proactive Deprescribing Among Older Adults With Polypharmacy: Barriers and Enablers. The Annals of Family Medicine. 2025;23(3):207-213. doi:10.1370/afm.240363
2. Ie K, Aoshima S, Yabuki T, Albert SM. A narrative review of evidence to guide deprescribing among older adults. J Gen Fam Med. Jul 2021;22(4):182-196. doi:10.1002/jgf2.464
3. Ando T, Sasaki T, Abe Y, et al. Measurement of polydoctoring as a crucial component of fragmentation of care among patients with multimorbidity: Cross-sectional study in Japan. J Gen Fam Med. Nov 2023;24(6):343-349. doi:10.1002/jgf2.651
4. Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother. Mar 2007;5(1):31-9. doi:10.1016/j.amjopharm.2007.03.004
5. Ie K, Hirose M, Sakai T, et al. Medication Optimization Protocol Efficacy for Geriatric Inpatients: A Randomized Clinical Trial. JAMA Network Open. 2024;7(7):e2423544-e2423544. doi:10.1001/jamanetworkopen.2024.23544