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The American Journal of Managed Care April 2015
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Clinical Provider Perceptions of Proactive Medication Discontinuation
Amy Linsky, MD, MSc; Steven R. Simon, MD, MPH; Thomas B. Marcello, BA; and Barbara Bokhour, PhD
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Clinical Provider Perceptions of Proactive Medication Discontinuation

Amy Linsky, MD, MSc; Steven R. Simon, MD, MPH; Thomas B. Marcello, BA; and Barbara Bokhour, PhD
A qualitative study to understand clinical providers' attitudes and beliefs about polypharmacy and their perceived barriers to and facilitators of appropriate medication discontinuation.
ABSTRACT
Objectives:
Polypharmacy and adverse drug events lead to considerable healthcare costs and morbidity, yet there is little to guide clinical providers in the area of discontinuing medications that may not be necessary. We sought to understand providers’ beliefs and attitudes about polypharmacy and medication discontinuation.

Study Design: Qualitative study using semi-structured interviews of 20 providers with prescribing privileges at 2 US Veterans Affairs Medical Centers, from April 2012 to October 2012.

Methods: Transcribed interviews were analyzed using grounded thematic analysis, a systematic approach to deriving qualitative themes from textual data.

Results: We identified 10 themes within 4 domains of medication discontinuation. Within the first domain (medication factors), we identified 2 themes: 1) medication characteristics, and 2) uncertainties of why a patient was taking a particular drug. Within the second domain (patient factors), we identified 3 themes: 3) clinical picture of the patient, 4) clinicians’ understanding of the patients’ knowledge and beliefs, and 5) patients’ adherence. Within the third domain (clinical provider factors), we identified 2 themes: 6) professional identity, and 7) providers’ decisions related to their own beliefs about medications. Within the fourth domain (system factors), we identified 3 themes: 8) multiple providers, 9) workload, and 10) external directives and policies such as structural components of a healthcare system.

Conclusions: Provider decisions to discontinue medications are affected by factors at all levels of the clinical encounter. Our findings have implications for development and implementation of interventions to improve appropriate medication discontinuation via enhanced medication reviews, enriched patient-provider communication, and better system-level structures. This, in turn, may reduce the continued prescribing of potentially inappropriate medications that can lead to adverse outcomes or increased healthcare costs.

Am J Manag Care. 2015;21(4):277-283
Take-Away Points
Clinical providers express concerns about polypharmacy but receive little guidance on how to make decisions about medication discontinuation. Until now, there has been little understanding of providers’ perceptions of factors affecting these decisions.
  • Factors at the level of medications, patients, providers, and the healthcare system itself contribute to decision making about medication discontinuation.
  • Understanding these factors will enable the development and implementation of interventions to improve appropriate discontinuation, and in turn, potentially reduce adverse drug events and uncontrolled healthcare costs.
Polypharmacy, often defined as a patient taking 5 or more medications,1 is common. Roughly 40% of adults 65 years or older experience polypharmacy, with a similar prevalence in active users of Department of Veterans Affairs (VA) facilities.2,3 A greater number of medications is associated with risk of adverse drug events (ADEs), which leads to increased healthcare utilization, costs, and morbidity.4,5 Moreover, physicians may interpret subtle adverse physiologic effects as a distinct problem and add medication to treat them; such a “prescribing cascade” can lead to increased rates of polypharmacy.6

Providers’ perceptions of polypharmacy, as well as barriers to and facilitators of mitigating it through proactive medication discontinuation, are unclear. Clinicians lack evidence of best practices for evaluating patients’ medication regimens to determine which drugs, if any, may safely be discontinued, especially for ambulatory care patients. Several studies have demonstrated the feasibility and safety of withdrawing particular classes of medications, but many focus on inpatients and residents of long-term care facilities.7,8 While medication adherence and medication reconciliation have emerged as health system priorities, little attention has been paid to promoting the discontinuation of medications that may not be necessary or whose benefits no longer outweigh associated risks. Experts have suggested that the “time until benefit” of a medication be compared with life expectancy in elderly populations to aid in decisions about its continued use.9 Whether clinicians consider such risk-benefit balances in the general adult population is unknown.

Appropriate cessation of a medication could lead to a reduction in ADEs and to improved health outcomes, yet little is known about factors that inhibit or facilitate providers’ discontinuation of medication. Therefore, we sought to understand how providers make decisions about medications in a complex population by identifying their beliefs and attitudes about polypharmacy, as well as their perceptions of the factors that influence decisions and actions related to medication discontinuation. Based on prior literature, we hypothesized 4 domains related to discontinuation: medication, patient, provider, and system (Figure); and we sought to identify key themes within each domain to inform future interventions to improve medication discontinuation.

METHODS

We conducted a qualitative study using in-depth interviews of primary care providers and pharmacists at 2 US VA Medical Centers. Qualitative methods are useful for understanding new areas and generating data to inform future research. We explored attitudes toward medication reconciliation, polypharmacy, patient-provider communication, and decision making about discontinuing medication. Institutional review boards at both sites approved the study.

Recruitment

At primary care staff meetings, the lead investigator (AL) introduced the study and distributed recruitment materials describing the project objective of understanding decision making, communication, and factors associated with medication discontinuation. Providers with prescribing privileges—including physicians, nurse practitioners (NPs), and pharmacists—were eligible to participate. Within the VA, clinical pharmacists are authorized to initiate, titrate, and discontinue medications. All eligible providers (n = 63) were subsequently invited to participate, and a convenience sample was scheduled for interviews. All participants provided written informed consent; no stipend was provided.

Data Collection

The lead investigator conducted individual, in-person, in-depth, semi-structured interviews of 30 to 60 minutes’ duration between April 2012 and October 2012. We queried providers’ views and conduct of medication reconciliation, communication with patients, interactions with colleagues, beliefs about medications, polypharmacy, and experience with discontinuing medications. The interviewer used the Interview Guide for Providers (see eAppendix, available at www.ajmc.com) flexibly and followed up on unanticipated issues raised by participants.

Analysis

Interviews were audio-recorded, transcribed verbatim, and reviewed for accuracy. Transcripts were analyzed qualitatively using procedures informed by grounded theory methodology,10 a systematic approach to deriving qualitative themes from textual data. This approach begins with open coding, in which investigators identify key concepts emerging from the language used by participants and assign codes (descriptive phrases) to segments of text. We began analyses using sensitizing concepts surrounding polypharmacy and medication discontinuation.11 Using NVivo qualitative analysis software (QSR International, Doncaster, Australia),12 the lead investigator and a research assistant (TBM) coded 4 interviews independently, and through discussion came to consensus on code definitions to develop a coding dictionary. The remaining interviews were coded by the lead investigator, who refined the dictionary as needed. Throughout, detailed coded text segments were reviewed, discussed, and revised if needed by 2 investigators (AL, BB) before the text was condensed into broader themes. Prominent themes and exemplifying quotes were discussed by the research team, and each theme was mapped to one of the 4 domains (medication, provider, patient, and system factors) that comprised our conceptual model. Themes that could have been mapped to multiple domains were assigned the best fit through consensus discussion.

RESULTS

We interviewed 20 providers (8 male, 12 female; 15 site A, 5 site B), with a range of experience in clinical practice (2 to 39 years; median 21) and in the VA (2 to 30 years; median 15). The majority (n = 11) were physicians, with 3 NPs and 6 pharmacists. Twenty interviews were sufficient to achieve thematic saturation, where at a certain point no new concepts appeared. Ten themes emerged, each mapping to 1 of 4 domains influencing the process of proactive medication discontinuation (Figure). Exemplifying quotes that best represent the general sense of each theme can be seen in the Table.

Medication Factors

Medication characteristics. Characteristics of medications, such as the number of daily doses, therapeutic duplication, or whether 1 medication could address 2 problems, influenced clinicians’ decisions when reviewing regimens. Many reported paying particular attention to specific medication classes as potential targets for discontinuation (eg, proton pump inhibitors, statins, opioid pain medications). Reducing or discontinuing pain medications was described as more complicated due to perceived patient reluctance.

Indication uncertainty. Providers spoke at length about the difficulties of decision making with unclear medication indications. Multiple reasons for uncertainty were suggested, such as a patient’s inability to state the reason for his medication, or the presence of an associated indication that might not reflect the true rationale for the medication’s use. For some of their patients, the default for some providers was to maintain the status quo in the absence of a clear reason to stop a medication, despite uncertainty. For other patients, a trial of discontinuation would evaluate its necessity.

Patient Factors

Clinical picture. Providers noted that the presence of multiple comorbid conditions—each of which might require 1 or more medications—inhibited discontinuation. Conversely, a geriatric patient’s age sometimes triggered discontinuation because of concerns related to polypharmacy, decline in drug metabolism, or shifts in the risk-benefit ratio due to changes in perceived life expectancy—especially for patients with terminal cancer. Impaired patient cognition also made clinical decision making difficult because of uncertainties about whether the recommended changes would be accurately understood and implemented.

The intended and unintended medication effects were key to medical decision making. Providers felt it was important to elicit whether a medication was providing symptomatic relief, despite noting that paradoxically, such evaluations were infrequent. In a related process, medications were often stopped on a trial basis to see if symptoms returned after discontinuation. Providers thought it important to assess for side effects warranting reactive discontinuation, but patient-reported side effects (eg, dizziness) were felt to be more difficult to ascertain than measurable ones (eg, low blood pressure).

Perception of the patient’s knowledge and beliefs. Another important factor influencing providers’ decisions to discontinue medications was their perception of the patient’s knowledge, beliefs, and preferences about taking medications. Clinicians spoke about how patients’ better comprehension of their conditions and medications often facilitated conversations about stopping a medication, albeit not always resulting in discontinuation. Patients viewed as having limited understanding made it challenging for clinicians to ensure that medications were taken as directed. At the same time, providers recognized that such patients often would “follow doctor’s orders,” thus facilitating discontinuation if called for.

Providers were influenced by patients’ beliefs about a medication's importance; clinicians felt that patients generally prioritize medications that treat symptoms (eg, pain or heartburn). Moreover, some providers endorsed the notion that patients receive “psychological comfort” from continuing medicines they have been taking for a long time.

Medication adherence. A major factor that challenged providers’ ability to make decisions about discontinuation was uncertainty regarding a patient’s adherence to medication. Clinicians often felt that even if they obtained an accurate medication list, questions remained about how consistently adherent patients were to those medicines. Many clinicians spoke about the need to have additional contact with the patient in order to derive an updated medication list—considered essential for prescribing decisions.

Provider Factors

Professional identity. Providers discussed how their background and job descriptions created a sense of identity that enabled them to make prescribing decisions. Many spoke about the responsibility they felt to provide appropriate, comprehensive care with ultimate accountability for medication decisions. Previous experience—and success—in discontinuing medications provided confidence for providers to attempt discontinuation in the future. Other providers expressed hesitation to alter regimens for a medication that fell outside their scope of practice, for which they had little experience prescribing, or that another clinician was actively managing.

 
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