A Pilot Study on the Views and Experiences of Healthcare Providers about Deprescribing Preventive Medications in Patients with Polypharmacy

doi:10.21203/rs.3.rs-4612136/v1

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A Pilot Study on the Views and Experiences of Healthcare Providers about Deprescribing Preventive Medications in Patients with Polypharmacy

https://doi.org/10.21203/rs.3.rs-4612136/v1

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Background

Deprescribing is a process of tapering or stopping medications to achieve improved health outcomes. The process is widely recommended to reduce the burden of polypharmacy in older or frail patients. Healthcare providers’ (HCPs) role has been reported to be important when deprescribing in clinical practice. Despite the potential, little is known about the views and experiences of HCPs about deprescribing in Indonesia. Therefore, this study aims to present the preliminary results of the views and experiences of HCPs in Indonesia about deprescribing medications in patients with polypharmacy.

Methods

The study was carried out using semi-structured interviews with three HCPs, comprising a general practitioner (GP), internist, and pharmacist, who were selected as informants. Interviews were recorded and transcribed verbatim, and directed content analysis was performed to extract the data.

Results

Themes about HCPs’ knowledge, skills, experience, and interaction between HCPs, patients, and patient families were found. Although the HCPs understood the importance of deprescribing, some challenges in implementing the process were admitted. These comprised a lack of specific guidelines, barriers to communication skills, building trust from the patients, and insufficient time and resources to support deprescribing decisions. Therefore, closer collaboration between HCPs and good interaction with patients and their families may be favorable when conducting deprescribing.

Conclusion

This first exploration study showed that there were most likely knowledge gaps in deprescribing practices in Indonesia, particularly regarding preventive medications in patients with polypharmacy. Consequently, studies involving more HCPs may help determine their roles in deprescribing and the barriers and enablers to implementation.

deprescribing

healthcare providers

polypharmacy

preventive medications

Deprescribing is a process of reducing or stopping medications to achieve improved health outcomes and manage polypharmacy, with the supervision of healthcare providers (HCPs) (1). In addition, deprescribing potentially inappropriate medication is widely recommended to reduce the burden of polypharmacy in older or frail patients (2, 3). Tools, such as the Beers list, are provided to identify drug treatments that must be avoided in most patients due to the high risk of adverse events (4). In recent years, deprescribing has attracted attention (5). This includes deprescribing of cardiovascular or diabetes medication, where an unfavorable balance exists between benefits and risks, and less strict targets are required (6, 7). Despite the potential, the practice has not been widely implemented, which causes overtreatment and increased risks of falls and medication-related hospitalizations.

In line with these results, several HCPs barriers and enablers that affect deprescribing have been identified (6, 7). These studies revealed that factors, such as knowledge and experience, as well as interaction with patients, families, and other workers played an essential role (6, 7). To implement deprescribing in clinical practice, HCPs are often in need of support and guidance. Consequently, various methods have been explored to guide practitioners, particularly in high-income countries. In Indonesia, pharmacists may collaborate with other HCPs to provide medications optimization, such as medication appropriateness, and to ensure the safety, efficacy, and adherence to medication (8). However, there is limited information on HCPs views and experiences about deprescribing in lower- and middle-income countries, including Indonesia, where the healthcare system, provider collaboration, and patient-HCP relationship are different. Therefore, this study aims to explore the views and experiences of HCPs in Indonesia about deprescribing preventive medications in patients with polypharmacy.

Study design and setting

Semi-structured interviews were conducted to qualitatively explore the views and experiences of Indonesian HCPs about deprescribing. The participants comprised general practitioner (GP), specialist (internist), and pharmacist. The inclusion criteria for HCPs were (1) had been practicing for at least two years and (2) gave the consent that conversation could be recorded. The interviews were carried out between February and March 2022 in Bahasa Indonesia through an online platform. This was to assist participants who resided far from the study facility (Bandung City) due to their different healthcare facilities in West Java Province. The selection of HCPs was carried out using convenience sampling as authoritative key informants. In addition, discussions were led by MPO (female), who was an investigator in a deprescribing-related field with experience and training in conducting qualitative studies. The interviews were recorded in the slot time of one hour to one hour 30 minutes, and participants were asked to give oral consent for the study and the recording video. Ethical approval was obtained from the Ethical Committee of Universitas Padjadjaran, Indonesia (No. 299/UN6.KEP/EC/2022).

Topic list

A topic list consisting of open-ended questions was used to guide the interviews, derived from lists and survey instruments that had previously been developed (9). Relevant subjects that described important factors related to HCPs’ views and experiences from the interview results were included (Additional File 1. Topic Guide).

Analyses

The interviews recordings as well as transcripts were carefully transcribed verbatim and checked for accuracy by the investigators, such as MPO, CTY, and SDA. Transcripts were separately coded by two investigators known as MPO and CTY. These codes were reviewed, refined, and sorted into a single coding for direct content analysis. In addition, thematic coding was applied to identify information related to the experiences and views of HCPs about deprescribing. The coding scheme was developed by MPO and CTY, with disagreements being discussed to reach a consensus with MPO, CTY, and RA. The final coding scheme was translated into English and checked by RA, a senior investigator with experience in qualitative study.

The COREQ-32 checklist (Consolidated criteria for reporting qualitative research) was used to report important aspects of qualitative study and precludes generic criteria of research reports (Additional File 2. COREQ-32 checklist) (10).

A GP, internist, and pharmacist were engaged in the personal interviews. In addition, GP worked in primary healthcare for seven years, the internist practiced in the hospital as well as the primary healthcare center for six years, and the pharmacist worked in the intensive care ward and outpatient geriatric unit in the hospital for eight years. All participants were workers in the health facilities in the West Java province, Indonesia.

The thematic analysis of the interviews exhibited four main themes, namely knowledge, skills, experiences, and interaction factors, which were connected and useful to extrapolate the views and experiences of HCPs about deprescribing.

Knowledge of HCPs

GP, internist, and pharmacist believed that deprescribing was important and necessary for implementation in targeted patients, such as the elderly as well as those with polypharmacy, or with no more symptoms to continue the medications. Based on their knowledge, the process was not about stopping or reducing the medications but maintaining the healthy lifestyles of the patients. For example, type 2 diabetes (T2D) patients who received polypharmacy must still maintain their diet and combine it with routine exercise. The medications could be reduced or stopped in this group when there was a well-controlled blood sugar level. Patients also needed routine control to measure glucose levels, blood pressure, and cholesterol levels as a precaution against cardiovascular complications.

HCPs revealed that the deprescribing process included personalized treatment, where patients’ condition, character, and preferences must be considered. For example, patients with complications, such as heart, kidney, or stroke issues were not likely to receive deprescribing. Meanwhile, those who maintained a healthy lifestyle, discipline, and adhered to medications had a higher chance of getting deprescribing.

In this study, HCPs were aware of the benefits of deprescribing, such as preventing unwanted events like drug reactions (ADRs) and re-hospitalization, which could result in the reduction of costs and increased patients’ adherence. However, all participants revealed that there were no specific guidelines and protocols in the clinical settings as the term was unfamiliar among colleagues. The implementation of deprescribing was predominantly shown in inpatient care, such as assessment to stop and reduce certain medications. In addition, it was possible to analyze patients’ responses after implementing the process.

“Deprescribing is important and needs to be implemented for polypharmacy geriatric patients. In those patients, deprescribing may prevent readmission to the hospital due to potentially inappropriate medications. Additionally, it can prevent adverse drug reactions, particularly in patients with well-controlled health conditions, like those with properly managed blood sugar levels.” (Pharmacist)

“Deprescribing is necessary because it can increase the adherence in the patients since they are already consuming many medications.” (Specialist)

“I recommend that diabetes patients with polypharmacy maintain a healthy lifestyle, such as exercise and a healthy diet. So, the patients will not only depend on the medications.” (GP)

“There are guidelines for treatment, such as guidelines for diabetes treatment, but no specific guidelines for deprescribing.” (GP)

Skills of HCPs

Open communication was one of the skills needed among HCPs in conducting deprescribing and discussing medications change, as it could help in achieving the agreed decision. When discussing the decision with patients, HCPs must educate and explain the major reason. For example, GP must explain to T2D patients that diabetes may not be completely curable, but it could be controlled with medications and a healthy lifestyle. Consequently, patients could have a mindset to maintain health and adhere to the given prescriptions.

After the implementation of deprescribing, there was a need for regular follow-ups to control underlying conditions. HCPs needed to assess the clinical and medical status to determine whether the blood pressure, glucose level, or lipid profile were under reasonable control. To perform this assessment, the knowledge and skills of HCPs were needed.

Adequate training was needed to fulfill knowledge and skills when conducting deprescribing. Although there was training among GP in primary healthcare on chronic disease management, it was not specifically about deprescribing. HCPs stated that the training performed was insufficient to accommodate the implementation of deprescribing in clinical practice. Therefore, more advanced training was needed to focus on each topic, such as diabetes, hypertension, cardiovascular diseases, and geriatric treatments. Separate training could also be conducted for each HCP and a combination of pharmacists, doctors, nurses, and specialist. In this context, HCPs could receive the same perception of deprescribing to enhance collaboration with others when making decisions.

“As doctor in charge, doctor should capable not only to treat patient, but also to educate patient.” (Specialist)

“However, because they received a different treatment than before, let's say a reduction or stopping of the medications, some patients may question the decision. Therefore, it will depend on the GP's ability to inform the patients.” (GP)

“General practitioners receive training on managing chronic diseases but are not focused on deprescribing. The implementation cannot be completed with just training. Still requires advice from internists or peers.” (GP)

“If we can do a follow-up action by phone or collaborate with homecare service, we can make sure when the antidiabetes medications are reduced or stopped. We are then aware of the follow-up condition of the patient.” (Pharmacist)

Experience of HCPs

HCPs often encountered challenges when performing deprescribing, such as patients’ clinical response, perception, and time constraints. When HCPs acknowledged that each patient required individualized decisions, considerations must be made for each clinical response. For example, diabetic patients could be given deprescribing, while others were not eligible. In addition, patients’ perceptions also became a challenge, where some patients believed that medications needed to be taken although they were in well-controlled health.

Shortage of time to complete an examination and evaluation for deprescribing, specifically for outpatient, was another challenge. Compared to inpatients, who were more likely to undergo the entire assessment procedure from the HCPs, outpatients were sometimes overlooked for this, especially during peak patient volume in primary care. Thus, HCPs had more patients than their could manage. Some patients in primary care sometimes did not regularly attend check-ups and pick up medications. Consequently, HCPs could only assess patients when medical records were complete. The participants mentioned that certain individuals succeeded in deprescribing, such as middle-aged under 60, well-educated, diabetic with well-controlled blood sugar levels, and relatively new diabetes patients with manageable glucose levels.

When medications were reduced or stopped, the responses of patients typically varied. However, most patients expressed satisfaction with the decision made, indicating that the treatment was effective and met the target. Few expressed uncertainty and doubts about the decision and were worried that when medications were stopped or reduced, the symptoms could worsen. Several patients were reluctant to decide due to the comfort experienced with the use of the current medications.

“… Some patients think that although they already in well controlled health, they feel they still want to take their medications, otherwise it feels wrong, like a psychological effect when patients taking medications for a long time.” (Specialist)

“There is no time to do medical assessments for outpatients. Although the patient consumes many medications, there is not enough time to complete the process (like inpatients). The comprehensive medical assessments also need to be done with the outpatients when doing deprescribing.” (Pharmacist)

“An example of my patients who can successfully get their medications reduced or stopped is aged 50–60; they are also educated patients” (GP).

“Most of the patients were happy when their medications were stopped or reduced. That meant the treatment was effective and reached the goal. Some patients expressed doubts about the choice, asking what would happen if the drugs were withdrawn or reduced. There were also reluctant patients because they were content with their current medications.” (Specialist)

Interaction between HCPs and patients, patients’ families, and other providers

Generally, patients preferred to communicate with HCPs about health and medications, where the suitable treatment could be decided. After trust had been earned, patients became open to participating in the conversation and discussing their condition and the treatment received. These individuals were typically more receptive to deprescribing when given a clear explanation. HCPs preferred when patients initiated the discussion about the medications.

The pharmacist admitted that discussing deprescribing directly with patients could be difficult because some trusted doctors more. Meanwhile, GP expected that these individuals would trust their decision about deprescribing. In some cases, patients who had previously received treatment from specialist occasionally had doubts about GP decisions. These individuals assumed that specialist was more knowledgeable than GP, leading to increased trust.

Regarding the support of partners and families, the HCPs revealed that partners and families must be actively involved when deciding on deprescribing, as their support was important. Specifically for older patients, partners or families could be of help in ensuring adherence and understanding the medications better.

A strong healthcare system, teamwork, and communication were necessary for effective deprescribing, where a GP, specialist, pharmacist, and nurse must be involved in the hospital setting. The HCPs acknowledged that there must be an appointed team for decision-making and conducting a follow-up to manage the uncertainty associated with the decision. However, this kind of collaboration in deprescribing had not been fully implemented in clinical practice. Although a team had been assembled, it was not yet operating effectively. In primary care, there was also no direct coordination between GP and specialist.

“I always explain to the patients if they get new medications or get their medications reduced or stopped. Patients are more accepting and have a positive response to the decision if they get such an explanation.” (Specialist)

“Family support is also essential, especially for older patients, because the family can remind them about their medications.” (Specialist)

“Discussing deprescribing directly with patients can be tricky because some patients only trust the doctor. (Pharmacist)

“I expect my patients to trust my decision. Sometimes, patients who have already been treated by specialist doubt the GP. They think specialist know better than GP and have more trust in them.” (GP)

“Deprescribing is important and needs to be implemented, but it is also tricky because it requires teamwork … Roles come not only from doctors but also from pharmacists and nurses or even specific teams in the geriatric unit.” (Pharmacist)

The four main themes that emerged from the results included knowledge, skills, experience, and interaction factors. These themes summarized the viewpoints and experiences of HCPs regarding deprescribing preventive medications in patients, specifically older patients and those with polypharmacy.

GP, the internist, and pharmacist understood the significance and benefits of deprescribing for targeted patients. HCPs recognized that deprescribing was part of good prescribing when it could focus on individualized treatment. It was also important for patients to maintain a healthy lifestyle. This idea was explained in the previous review that the medications evaluation process must determine whether the potential of a drug's harms outweighed the benefits by considering the actual function of the patient, life expectancy, and preferences (3).

It was noteworthy that the term deprescribing was unfamiliar to some of HCPs’ colleagues. Although reducing and stopping inappropriate or unnecessary treatment was carried out in clinical practice in Indonesia, the deprescribing concept still applied with varying degrees of precision, with no accepted definition in some countries (11). There were treatment guidelines for chronic diseases such as diabetes and cardiovascular diseases and health management guidelines for elderly patients (12–15). However, there were no specific guidelines and protocols for deprescribing in clinical settings. Several deprescribing networks and organizations around the world have started to support deprescribing in clinical practice specific for some treatments and conditions, such as deprescribing antihyperglycemic agents in older individuals and glucose-lowering medications (16–18). These sources could be adapted as guides according to the Indonesian settings.

HCPs expressed that good communication skills were helpful when discussing deprescribing with patients. With open communication between HPCs and patients, their trust in HCPs was gained, which was key to willingness to follow HCPs' suggestions. Previous studies indicated that the lack of communication skills of HCPs was an obstacle when building trust with patients for the deprescribing process (19, 20). Some HCPs required additional training on effective communication techniques regarding deprescribing antidiabetic and antihypertensive medications since it was a challenge for HCPs to shift the instruction and advice of taking such medications to stopping or reducing the medications.

Although there was already training arranged among GP in primary healthcare about chronic disease management, the training was insufficient for the implementation of deprescribing in clinical practice. In addition, HCPs could be supported with practical guidance and tools, tailored education, and targeted training to adequately address the limitation of conducting deprescribing (21). HCPs also need to enhance awareness of the available tools and instruments, such as validated lists and criteria to identify potentially inappropriate medications and apply deprescribing (22).

The HCPs had a challenge when handling different views of patient perceptions regarding medications. Some patients believed that medication was still needed, when in well-controlled health. Several patients were reluctant to stop medications because of their comfort with their current treatment. This attitude was related to how much of a burden patients had for treatment and which HCPs proposed the suggestion. A previous study in Indonesia showed that patients experiencing more burden for medications were more willing to stop medications when suggested by their doctor (23).

A complete examination and evaluation were needed to conduct deprescribing. More time and effort were required to perform a comprehensive medical review to reach a decision. However, a shortage of time and resources could be considered as a challenge, these barriers were also found in previous studies of deprescribing medications generally (2, 9, 19). Time management and organizational planning were general challenges found in hospital and primary care in lower- and middle-income countries (24, 25)

An established relationship between HCPs and patients supported the deprescribing process. The HCPs were not only aware of the medications review to decide which medications must be continued, stopped, or reduced, but also needed to strengthen relationship with patients. Ideally, each HCPs must be able to engage in two-way communication and take care of the patients with good attention, as well as build a reliable treatment process, so that patients could trust their decision to deprescribe (25). Nevertheless, patients could also exhibit trust challenges. The previous study among older T2D patients in Indonesia revealed that around two-thirds of those patients were willing to stop one or more medicines in general when their GP or specialist suggested it, but the willingness was lower when a pharmacist proposed deprescribing (23). Usually, GP had good continuity of care with patients; therefore, GP had a strategic role in implementing deprescribing as patients and their medications history were regularly seen.

The involvement of partners and families was important to support deprescribing, specifically when involved from the start of the discussion. This could reduce the reluctance of HCPs decisions that came from the families (9). The conversation about deprescribing with the families provided a prime opportunity for person-centered and shared-decision making (26)

Building strong teamwork and good communication among GP, specialist, pharmacist, and nurse was essential for effective deprescribing. This had been emphasized in the previous review on deprescribing strategy from a clinical and regulatory perspective (22). Multidisciplinary teams in hospitals created a structured medication review as well as promote therapeutic reconciliation and adherence to treatment are particularly useful in addressing the needs of polypharmacy management in older patients (27).

This first explorations showed that most likely knowledge gaps in deprescribing practices in Indonesia, specifically regarding preventive medications in people with polypharmacy. Future observational studies, qualitative studies, and randomized controlled trials could gather further evidence to guide HCPs in implementing deprescribing in clinical practice and specific high-risk patient groups, such as geriatric patients and those with chronic diseases such as T2D, hypertension, and cardiovascular diseases.

This was a pilot study with limited participants representing each HCPs’ role. The small-scale interviews were conducted to gather data that could enable the construction of a far-reaching framework and topic list for the following study. Despite the limited sample of interviews, the results developed some preliminary ideas on HCPs’ challenges and needs when implementing deprescribing. The follow-up study must investigate more specific aspects, such as the roles and responsibilities of each medical personnel, barriers and enablers in deprescribing, as well as how to implement deprescribing in clinical practice. A focus group discussion could be conducted among HCPs to observe the dynamic interaction in the group.

This study examined views and experiences concerning deprescribing medications in polypharmacy patients. Various standpoints of HCPs’ knowledge, skills, experience, and collaboration as well as interaction with patients and patients' families, were stated regarding deprescribing. The HCPs were aware of the importance of deprescribing for targeted patients. Some challenges were recognized, such as a lack of specific guidelines and protocols for deprescribing, barriers in communication skills and trust from the patients, and a shortage of time and resources to conduct comprehensive medications reviews to support deprescribing decisions.

In the future, promoting closer collaboration between HCPs to assist in the deprescribing process could be implemented. This first exploration study showed that there were more knowledge gaps regarding deprescribing practices in Indonesia. Therefore, future studies involving more HCPs could help determine their roles in deprescribing and the barriers and enablers in its implementation.

Ethics approval and consent to participate

Ethical approval was obtained from the Ethical Committee of Universitas Padjadjaran, Indonesia (No. 299/UN6.KEP/EC/2022).

Consent for publication

Not applicable.

Availability of data and materials

All data requests should be submitted to [email protected] for consideration. Access to the data recording and transcripts may be granted following review in consultation with the study team.

Competing interests

The authors declare no competing interests.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

The authors are grateful to all healthcare providers who participated in this study and shared the valuable experiences

Author Information

Authors and Affiliations

Universitas Padjadjaran (UNPAD), Faculty of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Bandung, Indonesia

Monika Pury Oktora, Sofa Dewi Alfian, Rizky Abdulah

Drug Utilization and Pharmacoepidemiology Research Group, Centre of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Jatinangor, Indonesia

Sofa Dewi Alfian, Rizky Abdulah

Institut Teknologi Bandung (ITB), School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Bandung, Indonesia

Cindra Tri Yuniar

University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands

Eelko Hak

Corresponding author

Correspondence to Monika Pury Oktora ([email protected])

Contributions

MPO and EH designed the study concept and methodology. MPO conducted the interview. MPO, CTY, SDA, and RA worked on project administration. MPO, CTY, and RA analyzed, investigated, and interpreted data. MPO drafted the manuscript. CTY, SDA, EH, and RA reviewed and edited the manuscript. RA and EH supervised the research. The authors read the final version, revised, and approved submission. The authors agree to be accountable for all aspects of the work.

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No competing interests reported.

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A Pilot Study on the Views and Experiences of Healthcare Providers about Deprescribing Preventive Medications in Patients with Polypharmacy

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Abstract

Background

Methods

Results

Conclusion

Background

Methods

Study design and setting

Topic list

Analyses

Results

Knowledge of HCPs

Skills of HCPs

Experience of HCPs

Interaction between HCPs and patients, patients’ families, and other providers

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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