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Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
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Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences

Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
Deprescribing could reduce the risk of harm from inappropriate medications. Understanding patient attitudes regarding which clinicians can make deprescribing recommendations can facilitate effective design and implementation of interventions.
ABSTRACT

Objectives: Deprescribing could reduce the risk of harm from inappropriate medications. We characterized patients’ acceptance of deprescribing recommendations from pharmacists, primary care providers (PCPs), and specialists relative to the original prescriber’s professional background.

Study Design: Secondary analysis of national Patient Perceptions of Discontinuation survey responses from Veterans Affairs (VA) primary care patients with 5 or more prescriptions.

Methods: We created 4 relative deprescribing authority (RDA) outcome groups from responses to 2 yes/no (Y/N) items: (1) “Imagine…a specialist…prescribed a medicine. Would you be comfortable if your PCP told you to stop...it?” and (2) “Imagine…your VA PCP prescribed a medicine. Would you be comfortable if a VA clinical pharmacist [Pharm] told you to stop…it?” Multinomial regression associated patient factors with RDA.

Results: Respondents (n = 803; adjusted response rate, 52%) were predominantly men (85%) and older than 65 years (60%). A total of 281 (38%) respondents said no to both questions (PCP-N/Pharm-N) and 146 (20%) said yes to both (PCP-Y/Pharm-Y). A total of 155 (21%) said no to a PCP stopping a specialist’s medicine but yes to a pharmacist stopping a PCP’s (PCP-N/Pharm-Y). A total of 153 (21%) said that a PCP could stop a specialist’s medication but a pharmacist could not stop a PCP’s (PCP-Y/Pharm-N). In adjusted models (reference, PCP-N/Pharm-N), those with greater medication concerns were more likely to respond PCP-Y/Pharm-Y (odds ratio [OR], 1.45; 95% CI, 1.09-1.92). Those with more interest in shared decision making were more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04-1.92). Those with greater trust in their PCP were less likely to respond PCP-N/Pharm-Y (OR, 0.52; 95% CI, 0.34-0.81) but more likely to respond PCP-Y/Pharm-N (OR, 2.16; 95% CI, 1.31-3.56) or PCP-Y/Pharm-Y (OR, 1.83; 95% CI, 1.13-2.98).

Conclusions: Understanding patient preferences of RDA can facilitate effective design and implementation of deprescribing interventions.

Am J Manag Care. 2019;25(4):192-198
Takeaway Points

Patients vary in their attitudes toward which providers have the authority to deprescribe medications.
  • In this study, 38% of respondents indicated that they would not want their primary care provider (PCP) to discontinue a medication prescribed by a specialist, nor would they want a clinical pharmacist to discontinue a medication prescribed by the PCP.
  • At the other end of the spectrum, 20% of patients indicated comfort with both their PCP and a pharmacist deprescribing a medication prescribed by a specialist and PCP, respectively.
  • Understanding patient preferences for and attitudes toward who can make deprescribing recommendations can facilitate effective design and implementation of interventions.
Overuse of medication can lead to an array of unintended consequences, including adverse drug events, drug–drug interactions, financial hardship, and decreased patient satisfaction.1-3 Polypharmacy—often defined as 5 or more medications—is estimated to affect more than 1 in 3 adults older than 65 years, and up to 79% of older adults may be prescribed a potentially inappropriate medication.4,5 One approach to reducing these harms is deprescribing, defined as the proactive, intentional discontinuation of a medication that either no longer provides the expected outcomes or has potential harms that outweigh potential benefits.6,7 Deprescribing should be considered part of the good prescribing continuum, incorporating patient preferences and goals of care into that decision-making process.8 Nevertheless, the best way to integrate deprescribing into routine clinical care remains unclear.

A barrier to effective deprescribing occurs when patients receive care from multiple clinical providers,9 especially across multiple healthcare systems. Such fragmentation of care can create uncertainties as to which clinician is responsible for managing a particular medication. When multiple providers care for 1 patient, some clinicians may be reluctant to make decisions about a treatment plan initiated by another.10 This reluctance may result from feeling that the clinical problem is beyond their scope of practice, uncertainty about the original prescriber’s intentions, or hesitance to interfere with another professional’s opinion.11 The difficulties of delineating clear roles for primary care providers (PCPs) and specialists have persisted for decades.12 Some have attempted to define a hierarchy of care from simpler to more complicated problems, describing roles for nurses, PCPs, and specialists.13 Parsing clinical responsibilities, including the ability to deprescribe, has become even more complicated as the professional jurisdiction and autonomy of nurse practitioners, physician assistants, and clinical pharmacists have expanded.14-16

Deprescribing is not only a provider behavior but also requires that the patient follow the recommendation. Patients may accept and follow deprescribing recommendations from some providers and not others. Some patients believe that their PCP is responsible for overseeing all care management and is able to change the plans of specialists; other patients preferentially value the additional training obtained by specialists.17 Patients’ perceptions may also vary based on the severity of their medical condition or their relationship with the clinician. It is important to ascertain the extent to which patients accept the authority of any individual provider to deprescribe a medication. Given the unknown influence of provider type on patient interest in deprescribing, we sought to characterize patients’ willingness to accept the deprescribing of medicines by different providers as might occur in the context of a hierarchy of professional authority.

METHODS

Study Design, Setting, and Population

We conducted a national mail survey of veterans receiving Veterans Affairs (VA) primary care. We used the VA Corporate Data Warehouse to identify patients with 5 or more concurrent prescriptions for 90 days in the medical record, at least 1 primary care visit during that same time frame, and at least 1 additional visit in the prior year. We identified 448,155 patients and randomly sampled 1600 subjects. This sample size was based on (1) guidelines for adequate sample size required for the primary psychometric analyses18 and (2) anticipated response rates. Women constituted 5.7% of the population sampling frame but were oversampled to constitute 15% of the mail-out sample to ensure adequate representation.

Survey Instrument

The Patient Perceptions of Discontinuation (PPoD) instrument is a psychometrically validated survey with 43 medication discontinuation–related items; it includes 8 attitudinal scales and 14 patient characteristic and background items.18 It includes 3 previously established multi-item scales: Beliefs about Medicines Questionnaire (BMQ)–Overuse, focused on overreliance on medicines; Trust–provider, assessing provider motivation; and CollaboRATE, reflecting shared decision making.19-21 Five additional PPoD scales consist of a combination of new items and selected items from pre-existing scales.22,23 Medication Concerns addresses medication effects. Provider Knowledge is about the PCP’s aptitude. Interest in Stopping Medicines assesses current deprescribing interest. Patient Involvement in Decision Making explores participating in medical care. Unimportance of Medicines measures patients’ opinions of the lack of benefit and/or potential harms of their current medicines. We modified CollaboRATE responses to a scale of 1 to 5 to maintain consistency with other scales, where 1 equals “no effort” and 5 equals “every effort.” All other PPoD scales use a 5-point response scale, where 1 equals “strongly disagree” and 5 equals “strongly agree,” with a neutral midpoint. Each scale score is an average of responses to individual items within that scale. Additional survey items address actual and hypothetical deprescribing experiences, as well as respondent characteristics (including self-reported health status, medical conditions, and healthcare utilization [eg, outpatient visits, hospital admissions, and other residential care]).


 
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