Abstract
Background:
Health systems are increasingly implementing interventions to reduce older patients’ use of low-value medications. However, prescribers’ perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood.
Objective:
To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians.
Design:
Qualitative study using semi-structured interviews.
Setting:
Academic and community primary care practices within University of Pittsburgh Medical Center health system.
Participants:
Sixteen primary care physicians.
Measurements:
We elicited 16 prescribers’ perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing.
Results:
We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable.
Conclusions:
Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians’ perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.
Keywords: deprescribing, low-value care, medication value, polypharmacy
BACKGROUND
Low-value care, defined as use of a health service whose costs or harms supersede its benefits, is a major driver of wasteful healthcare spending and exerts physical, psychological, and financial harm upon patients. Low-value prescribing manifests as the use of ineffective, unsafe, or overly expensive medications, and may result in polypharmacy. Over 40% of adults aged 65 and older are subject to polypharmacy (i.e., the use of ≥5 medications), which results in financial hardships, as well as increased risk of adverse drug events and hospitalizations.1,2
There has been increasing emphasis on deprescribing, defined as the discontinuation or reduction in dose of low-value medications in the context of a patient’s clinical status and healthcare preferences.3 Nevertheless, low-value prescribing and polypharmacy remain common in older adults.4 Although various approaches to deprescribing low-value medications have been studied, little is known about prescribers’ perspectives on healthcare value as they relate to medication use and their perceived incentives to engage in or avoid prescribing new low-value medications or deprescribing low-value medications that a patient was previously taking.5,6 This knowledge may empower health systems and payers to devise interventions that align with prescribers perceived incentives and disincentives to engage in low-value prescribing and more effectively avoid the excess costs and risks associated with low-value medication use and polypharmacy.
Thus, our objective was to characterize how prescribers understand the concept of medication value, their incentives to engage in or avoid low-value prescribing, as well as their perspectives on the acceptability of interventions that would most effectively disincentive new low-value prescribing and facilitate the deprescribing of previously prescribed medications in older adults.
METHODS
Study design and sample
During September and October of 2019, we performed semi-structured interviews of primary care providers who care for patients aged 65 and older. We chose this approach to best characterize providers’ detailed perspectives on low-value prescribing practices and elicit any potentially sensitive themes that they may be reluctant to share in a group setting, such as their own experiences and incentives to engage in low-value prescribing.
We recruited a mix of primary care providers who practice family medicine, general internal medicine, or geriatrics within a large not-for-profit healthcare system (University of Pittsburgh Medical Center), which is composed of 40 academic, community, and specialty hospitals with 700 outpatient practices located throughout Pennsylvania, New York, and Maryland. We sent a general email solicitation to clinicians affiliated with the Divisions of General Internal Medicine and Geriatrics and the Department of Family Medicine throughout the UPMC System. Physicians who reported providing primary care for patients aged 65 and older and practicing clinically at least one-half day per week were eligible to participate. We sought to recruit participants who exhibited diverse characteristics that could influence their views regarding low-value prescribing, such as their gender, specialty within primary care (i.e., general internal medicine, family practice, geriatrics), and practice setting (i.e., academic or community). Our recruitment goal was 15–20 healthcare providers based upon accepted qualitative research standards to achieve high likelihood of thematic saturation.7
Data collection
An interviewer trained in qualitative research methods (Alicia Dawdani) conducted 30–40 min telephonic semi-structured interviews. The interview script was developed collectively by the research team, further refined by the qualitative expert (Megan E. Hamm), and pilot tested by a generalist internist before use in the study. It addressed providers’ broad perspectives related to value and medication use, their incentives to engage in or avoid low-value prescribing, examples of specific low-value prescribing practices, and the acceptability of health system-level interventions to reduce low-value prescribing and enhance the value of medication use in older adults (see Supplementary Text S1). The interviews were semi-structured, meaning that the interviewer asked all questions of each participant, but was able to ask additional questions to clarify responses and to follow-up on unexpected topics as necessary. Each interview was audio recorded and transcribed verbatim.
Codebook development and data analysis
Two members of the research team (Eric L. Walter and Alison Decker) developed the codebook by applying the editing organizing approach as described by Crabtree and Miller.8 Before its application, the codebook was refined by the principal investigator (Thomas R. Radomski). After each code was defined, the same members of the research team (Eric L. Walter, Alison Decker) independently applied the codebook to each interview, after which they met to reconcile any discrepancies in their coding. Once coding was complete, one member of the research team (Eric L. Walter) and the principal investigator (Thomas R. Radomski) conducted a thematic analysis to identify the most salient themes within the data.9,10 The themes were then reviewed by another member of the research team (Alison Decker) as a form of investigator triangulation. Thematic saturation, defined as the point at which no new perspectives emerged from the interviews, was achieved.
RESULTS
Participants
Overall, 16 primary care physicians (11 from General Internal Medicine, 2 from Family Medicine, and 3 from Geriatrics) representing 6 distinct practice sites participated in the study (Table S1). Ten of the participants were female and all were non-Hispanic white. Overall, participants practiced medicine following residency for a median of 15 years, with a median of 5 clinical half-days of practice per week. Nearly all (n = 14; 93%) had appointments as medical school clinical faculty, regardless of practice setting.
Factors impacting medication value
We identified several key themes. First, prescribers considered low-value prescribing to be common. They readily identified several key factors that routinely impact the value of medications used by older adults, which we broadly characterized as “medication -related” (i.e., properties inherent to a medication that reduce its value), or “patient-related” (i.e., characteristics inherent in a patient that reduce the value of a medication prescribed to someone with that characteristic). Prescribers described 43 separate medications or medication classes as potentially low-value (Supplementary Text S2) based upon these characteristics.
Prescribers cited the potential for adverse drug events such as bleeding, falls, and kidney injury as the medication-related factors that most often reduce a medication’s value. These factors were important to prescribers because they can easily offset the intended benefits of prescribed medications, and their negative effects can compound when patients are prescribed multiple medications. Several prescribers also stated that medications that require an extended period of time to have an effect, such as statins, are often of low-value, as older adults many not live long enough to realize the benefit of these medications (selected quotes in Table S2). This concept, referred to in the literature as “time horizon,” was closely related to one of the most often mentioned patient-related characteristics: limited life expectancy.11,12
Prescribers also often cited cognitive impairment, comorbidities such as chronic kidney disease, and overall frailty as patient-related factors that most commonly reduce a medication’s value (Table S2). Non-medical patient-related factors, such as ability to pay for a prescription or manage the logistical challenges surrounding a prescription’s use, also contributed to prescribers’ assessment of whether a medication was potentially of low value. For patients who struggle to afford their medications, prescribers described how paying for low-value medications could crowd out other expenses like healthy food or other bills (Table S2).
Factors driving low-value prescribing
The second major theme we identified was that prescribers saw the drivers of low-value prescribing as multifactorial, but mostly deriving from three distinct domains: those related to qualities and behaviors of patients (here referred to as patient factors); those related to qualities and behaviors of prescribers, both primary care and specialty (referred to as prescriber factors); and those related to the organization of the healthcare system as a whole (referred to as health system factors). Prescribers described these factors as combining in such a way to make low-value prescribing seem to many prescribers as the default option, which was often difficult to overcome. As one provider stated, “the outpatient clinical environment is very busy and… there are so many things to talk about in an office visit that going through the medications and really trying to figure out if something is low value for the patient… that sometimes doesn’t make it to my to-do list for that office visit.”
Patient and prescriber factors
Providers consistently identified patient preference as a significant driver of low-value prescribing, in that patients are often reluctant to stop a medication, even in response to counseling. The reasons for this varied by patient, including anxiety about changing medications they have been on for a while, skepticism about changing medical recommendations, and strong opinions regarding their own care (selected quotes in Table S3). Regarding prescriber factors, deference to subspecialists was widely cited as a factor leading to increased prescribing of potentially low-value medications. According to one prescriber, “we’re not really practicing in teams, and especially for deprescribing but even for prescribing you may know that even if I don’t prescribe this[medication], when they go to the cardiologist, they’re gonna get it.” Both the pressure from patients and pressure from subspecialists combine to make it difficult and time consuming to avoid prescribing low-value medication, and even more so to deprescribe low-value medications a patient is already taking; we describe this challenge as “prescribing inertia” (Table S3).
Health system factors
Prescribers often saw quality metrics and other incentives as being perversely misaligned towards the initial prescribing and continuation of low-value medications. One prescriber described how “we’re judged continuously at work by certain metrics and we have to achieve certain percentages of patients who are doing what the authorities would believe is the right thing but might not necessarily be the right thing for all patients. So we may be ordering… meds that under normal circumstances we may think are not the right thing to do.” Other prescribers spoke about how health systems innovations designed to simplify healthcare delivery, such as automated refills of existing prescriptions, can backfire if they are not always updated to reflect deprescribing. According to one prescriber, “some drug stores will actually call our clinic for refills” even after they discontinued a medication, and as a result “I frequently just click ‘okay’ for the refill… if the pharmacy is requesting it,” leading to inadvertent continuation of low-value medications. These factors contribute to an overall sense shared by many prescribers that their incentives did not align with providing high-quality, high-value care (Table S3).
Approaches to address low-value prescribing
Engaging multidisciplinary teams
The third key theme described by physicians was that interventions designed to address low-value prescribing must address the drivers of low-value prescribing if they are to be successful. Potential solutions suggested by prescribers can be organized into three principal categories: engagement of multidisciplinary teams; improved utilization of the electronic medical record; and better targeting of incentives for physicians including quality metrics, financial incentives, and feedback. Engagement of multidisciplinary teams was mentioned by many prescribers as crucial because it provides prescribers with the support needed to avoid low-value prescribing (selected quotes in Table S4). Prescribers described how deficits in “time, bandwidth, and… medical knowledge” made it difficult to reduce low-value prescribing, and engaging multidisciplinary teams enabled prescribers to more easily engage in high-value prescribing by overcoming the time and cognitive pressures these deficits caused (Table S4).
Regarding multidisciplinary teams, several prescribers commented on how pharmacists can be helpful, with one describing in favorable terms how at their hospital “if [a physician] ordered something… that’s only meant to be for a certain indication or certain population of patients, [the pharmacy will] check you on that, and so that might disincentivize you from ordering a medication for someone where it’s not really appropriate.” Other prescribers suggested nurse navigators or even patients themselves as potential allies (Table S4). Overall, prescribers suggested that utilizing the full spectrum of care team workers would be “a good way of spreading the onus and the responsibility for helping to address these needs” rather than relying entirely on the labors of prescribers themselves.
Improved EMR utilization
Improved utilization of the electronic medical record was another issue that many prescribers described as important in addressing low-value prescribing. Multiple prescribers described alerts within the EMR designed to prompt reconsideration of medications that may be low-value as potentially useful, but also as a double-edged sword because “we have too many [pop up alerts], and so some of them get ignored.” However, most prescribers thought EMR alerts had the potential to be useful if they were better designed to be more intelligently targeted to their needs. Specifically, some prescribers thought EMR alerts had the potential for greatest impact if prescribers saw them before initiating a new medication that was potentially low-value (Table S4). This contrasted with repeated alerts once a decision to prescribe had already been made, which prescribers felt would be less helpful because it increased cognitive load by requiring them to re-address decisions they had already considered rather than assisting with the initial decision-making process. By intelligently designing EMR alerts, health systems can address one of the key health system factors behind low-value prescribing as well as addressing one of the sources of “prescribing inertia.”
Improving incentive structures
Many prescribers remarked that improving prescribers’ monetary and non-monetary incentives to avoid low-value prescribing could be a potentially effective way to reduce low-value medication use, as misaligned incentives was one of the key drivers of low-value prescribing cited by prescribers. Many prescribers expressed skepticism that financial incentives could be properly targeted to promote good care because prescribing decisions are so individualized and therefore difficult to capture with an algorithm. As one prescriber said, “a lot of these things are very individualized and there may be reasons why you choose to keep someone on a medication even if it is ‘low-value broadly speaking’,” although some did think that properly designed financial incentives could be useful (Table S4). Most prescribers, however, thought non-monetary methods of nudging prescribers towards higher value prescribing would be more useful. One method mentioned by several prescribers was simply having clear prescribing criteria on a system-wide level. As one prescriber described, this helps provide leverage in dealing with patient preferences because “if there’s a criterion for getting a medication [and] the patient doesn’t need it, that sort of forces my hand.” Although physicians were generally opposed to insurers not covering certain medications, several thought that not covering a brand name medication was acceptable if there was a generic alternative (Table S4).
Unacceptable interventions
Prescribers also described multiple ways in which potential interventions could make the issues underlying low-value prescribing worse by increasing the workload and time pressures burdening primary care physicians. Interventions that expect physicians to make changes alone without support on a system-wide level are likely to fail because “there’s no dedicated time to get any of this done so… you’re basically asking people to give up more of their personal time to reach this goal which I think is something people struggle with.” Specifically, prescribers stressed the need for potential interventions to avoid an adversarial approach such as directly contradicting prescribers’ decisions or requiring additional paperwork for them to justify their decisions (Table S4).
DISCUSSION
Among a cohort of physicians who provide primary care to older adults, low-value prescribing was seen as occurring commonly in clinical practice, and prescribers often described low-value prescribing as difficult to address once initiated due to the prescribing inertia that occurs as a result of a variety of patient, provider, and system-level factors. Despite these difficulties, prescribers were interested in opportunities to reduce low-value prescribing. However, their support was contingent on health systems and payers designing policies and interventions that incentivize high-value prescribing by addressing prescribers’ challenges and concerns rather than further contributing to prescribers’ administrative workload and potential for burnout.
Our study adds to the literature by examining prescribers’ attitudes not only to deprescribing narrowly, but also regarding what defines low-value prescribing more generally. In addition, our findings demonstrate how health systems and payers can use this information to design interventions that broadly decrease the initiation of new low-value medications and encourage the deprescribing of chronic low-value medications. Several prior studies have investigated the barriers towards deprescribing in the primary care setting. Anderson et al. identified four such barriers: awareness, inertia, self-efficacy, and feasibility.13 Similar results were seen in multiple studies examining the barriers to deprescribing, which one prescriber described as “swimming against the tide” of numerous systemic factors.14–16 Our findings align with this work by demonstrating that both patient and health system factors contribute to low-value prescribing, while building on these studies by identifying ways in which institutions may mitigate these issues in a way that is acceptable to prescribers. The results of this study also reinforce the conceptual framework for deprescribing developed by Linsky et al., further demonstrating that the theoretical categories of patient, provider, and system factors they posited represent a useful framework for conceptualizing factors affecting low-value prescribing.17 Our findings, in conjunction with these prior studies, suggest that prescribers may be enthusiastic to address low-value prescribing if this can be done in collaboration with institutional partners who actively seek to dismantle the many systemic barriers that facilitate low-value prescribing.
One crucial avenue for supporting physicians in reducing low-value prescribing will be bridging the gap between prescribers and patients regarding perceptions of low-value prescribing. Numerous studies have examined the attitudes of patients towards deprescribing.18–21 In these studies, patients often reported a desire to reduce their total medications (especially among those taking many medications) and were willing to actively participate in decision-making around deprescribing, but expressed anxiety and fear in questioning their doctor’s decisions about medication use. Our research suggests that prescribers may be more interested in deprescribing than patients believe. In fact, the way in which prescribers characterized and prioritized deprescribing medications closely mirrored the way patients prioritize taking and adjudicating the value of their medications.22 For example, prescribers prioritized potentially harmful medications such as those included in the Beers List, while assigning a secondary importance to deprescribing medications seen as simply ineffective (see Supplementary Text S2). Initiatives that prompt prescribers and patients to collaborate on deprescribing specifically and reducing low-value prescribing generally have the potential to empower both prescribers and patients to align their views on medication and thus improve value in prescribing.
Our findings also have important implications for health systems and payers. Knowing the characteristics of interventions that prescribers see as acceptable and potentially effective will help health systems and payers design interventions to reduce low-value prescribing that are more likely to be adopted and effectively implemented in clinical practice. For example, prescribers preferred engagement about medication value before the initial prescription of a low-value medication over more reactive deprescribing interventions that have been gaining in popularity. Prescribers were also open to deprescribing interventions that they saw as providing a tool for assisting their decision-making rather than questioning it. One way health systems can achieve this is by engaging multidisciplinary teams that work together towards a shared goal of increasing value in prescribing, rather than having the burden of doing so fall on prescribers alone.
Our study has important limitations. First, our study cohort contained 16 prescribers, however, the high degree of concordance among prescribers suggests that we adequately achieved thematic saturation. Second, the prescribers in our survey were all physicians, so our results may not reflect the attitudes held by NPs and PAs that also act as primary care prescribers. Third, while we were able to achieve adequate diversity in the gender and sub-specialties of the prescribers included in our study, all those who ultimately agreed to participate identified as non-Hispanic white, which largely reflects the demographic makeup of physicians practicing within UPMC. Therefore, our findings may not generalize to prescribers of other racial and ethnic backgrounds, and their views warrant further exploration. Fourth, while our study examined prescribers’ attitudes towards theoretical interventions, we have not observed prescribers during clinical encounters to confirm whether their responses are an accurate indicator of their behavior or represent more idealized responses.
CONCLUSION
Low-value prescribing is perceived to be common among primary care providers, despite consistent recognition of its importance and prescribers’ willingness to reduce it. Our findings highlight the importance of understanding prescribers’ attitudes towards and incentives to engage in low-value prescribing to design effective, well-received interventions to increase value in outpatient primary care prescribing among older adults.
Supplementary Material
Table S1 Describes demographic and professional characteristics of physician respondents.
Table S2 Selected quotations characterizing prescribers’ views on medication value.
Table S3 Selected quotations characterizing drivers of low-value prescribing.
Table S4 Selected quotations characterizing acceptability of proposed interventions.
Supplementary Text S1 The interview guide used for each of the qualitative interviews.
Supplementary Text S2 Medications cited by interviewed prescribers as being potentially “low-value”, categorized by frequency of citation.
Key Points
Prescribers characterized low-value prescribing based upon features of the medications themselves and of the particular patients to whom they were prescribed.
Prescribers identified causes of low-value prescribing related to patients, prescribers, and the health system as a whole, which combined to make low-value prescribing a default practice pattern
Interventions addressing low-value prescribing must address factors like cognitive load and time pressures that cause low-value prescribing to be common.
Why Does this Paper Matter?
Prescribers’ views on the drivers of low-value prescribing influence the acceptability of initiatives designed to reduce it. These findings may empower multidisciplinary healthcare teams, patients, and health systems to more effectively partner with prescribers to achieve high-value prescribing.
ACKNOWLEDGMENTS
FINANCIAL DISCLOSURE
Funding was provided by a Career Development Award from the National Institute on Aging, K23AG061217 (PI: Radomski).
Funding information
National Institute on Aging, Grant/Award Number: K23AG061217
SPONSOR’S ROLE
Funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
CONFLICT OF INTEREST
The authors have no conflicts of interest, financial or otherwise, to disclose.
This paper was presented virtually as a poster at the 2020 Society of General Internal Medicine Annual Meeting.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1 Describes demographic and professional characteristics of physician respondents.
Table S2 Selected quotations characterizing prescribers’ views on medication value.
Table S3 Selected quotations characterizing drivers of low-value prescribing.
Table S4 Selected quotations characterizing acceptability of proposed interventions.
Supplementary Text S1 The interview guide used for each of the qualitative interviews.
Supplementary Text S2 Medications cited by interviewed prescribers as being potentially “low-value”, categorized by frequency of citation.