INTRODUCTION
Polypharmacy, often defined as the use of five or more prescription medications, is associated with negative clinical outcomes.1 The use of potentially inappropriate medications (PIMs), such as those with greater risk of drug-drug and drug-disease interactions, limited patient-centered benefits, or lack of appropriate indication, also increases the risk of negative clinical outcomes, especially among older people.2 The use of PIMs is common, particularly in patients experiencing polypharmacy, and was found in 59% of patients.3
Deprescribing, or the clinical process of stopping medications that may cause harm or lack benefit, is one approach to combat polypharmacy and PIMs use.4 Studies have shown that deprescribing can reduce falls5 and can improve cognition and perceived health.6 Understanding patient, prescriber, and pharmacist attitudes, beliefs, and behaviors regarding deprescribing is essential to the rational design of interventions that promote and support deprescribing. We surveyed primary care clinicians, community pharmacists, and patients (reported separately) to compare their perceptions of deprescribing and inform the development of a deprescribing intervention.
METHODS
We conducted a cross-sectional survey of community-based primary care clinicians (“clinicians”) and community pharmacists (“pharmacists”) across Kentucky. We aimed to recruit 100 clinicians and 100 pharmacists. Survey invitations were sent electronically through professional society listservs between December 2019 and February 2020 (unavailability of data on listserv membership precludes response rate calculation). We used REDCap, a secure web application for building and managing online surveys and databases, to collect survey data.
We adapted the validated deprescribing instrument created by Linsky et al.7 to better match the clinical practice setting of our target population. Survey questions addressed deprescribing experiences, beliefs, attitudes, influencing factors, barriers, and facilitators.
We calculated means and standard deviations for continuous data and frequencies and percentages for categorical data. Data analyses were performed using IBM SPSS version 25. This study protocol was approved by the Institutional Review Board of the University of Kentucky (IRB# 53162).
RESULTS
Overall, 306 respondents (248 pharmacists and 58 clinicians) completed the survey. Average age of respondents was 45.5 years; 57.5% of the sample was female and 85.9% was non-Hispanic white. Pharmacists and physicians had positive attitudes toward deprescribing (M = 6.01 and M = 6.50, respectively; 7-point scale). Pharmacists and clinicians agreed that deprescribing is effective (M = 4.17 and M = 3.89; 5-point scale). Pharmacists believed that clinicians are important for deprescribing (M = 4.23), and clinicians reported that pharmacists are important for deprescribing (M = 3.90). Factors with the greatest influence on deprescribing for pharmacists and clinicians were medication-related adverse side effects (M = 3.84 and M = 3.68; 4-point scale) and patient characteristics like age, comorbidities, and functional status (M = 3.66 and M = 3.39).
Pharmacist- and clinician-reported facilitators and barriers to deprescribing are listed in Table 1. Pharmacists’ top three barriers were (1) difficulty communicating directly with other healthcare providers, (2) insufficient time available to spend with patients, and (3) lack of trust between healthcare providers and pharmacists. Clinicians’ top three barriers were (1) patient attitudes toward the medications they take, (2) insufficient time available to spend with patients, and (3) difficulty communicating directly with other healthcare providers. Pharmacists’ top three facilitators for deprescribing mirrored their barriers: (1) ability to communicate directly with healthcare providers; (2) adequate time to spend with patients, and; (3) trust between healthcare providers and pharmacists. Clinicians’ top three facilitators were (1) adequate time to spend with patients (2) trust between healthcare providers and patients, and (3) patient attitudes toward the medications they take.
Table 1.
Clinician (N=58) and pharmacist (N=248) perceived barriers and facilitators to deprescribing
| Pharmacists (N = 248) | Clinicians (N = 58) | |||
|---|---|---|---|---|
| Facilitators | Total Endorsed* | % | Total Endorsed* | % |
| Ability to communicate directly with healthcare providers about deprescribing recommendations | 124 | 50.0% | 18 | 31.0% |
| Adequate time to spend with patients to discuss deprescribing recommendations | 114 | 46.0% | 29 | 50.0% |
| Trust between healthcare providers and pharmacists | 86 | 34.7% | 2 | 3.4% |
| Training and experience with deprescribing | 68 | 27.4% | 22 | 37.9% |
| Trust between patients and pharmacists | 68 | 27.4% | 1 | 1.7% |
| Clinical guideline updates that support deprescribing recommendations | 63 | 25.4% | 20 | 34.5% |
| Access to electronic health records | 59 | 23.8% | 4 | 6.9% |
| Patient attitude toward the medications they take | 49 | 19.8% | 27 | 46.6% |
| Payment/financial incentive for making deprescribing recommendations | 41 | 16.5% | 5 | 8.6% |
| Personal beliefs in the value of deprescribing | 29 | 11.7% | 13 | 22.4% |
| Trust between healthcare providers and patients | 26 | 10.5% | 28 | 48.3% |
| Barriers | ||||
| Difficulty to communicate directly with other healthcare providers (e.g. subspecialists) about deprescribing recommendations | 139 | 56.0% | 27 | 46.6% |
| Insufficient time available to spend with patients and communicate deprescribing recommendations | 123 | 49.6% | 34 | 58.6% |
| Lack of trust between healthcare providers and pharmacists | 79 | 31.9% | 4 | 6.9% |
| Perceived authority of pharmacists to discontinue a medication (pharmacist only) | 66 | 26.6% | 0 | 0.0% |
| Lack of access to information in electronic health records | 65 | 26.2% | 12 | 20.7% |
| Lack of education and training related to deprescribing activities | 52 | 21.0% | 12 | 20.7% |
| Patient attitudes toward the medications they take | 51 | 20.6% | 40 | 69.0% |
| Lack of payment/financial incentives to make deprescribing recommendations | 45 | 18.1% | 4 | 6.9% |
| Healthcare culture that encourages a “more is better” approach | 42 | 16.9% | 17 | 29.3% |
| Lack of trust between healthcare providers and patients | 26 | 10.5% | 9 | 15.5% |
| Insufficient clinical resources (e.g., guidelines) to support deprescribing recommendations | 25 | 10.1% | 7 | 12.1% |
| Lack of trust between patients and pharmacists | 18 | 7.3% | 2 | 3.4% |
| Inability to obtain pharmacist input on deprescribing (clinician only) | 0 | 0.0% | 6 | 10.3% |
Number of respondents selecting item as a top three facilitator or barrier to deprescribing
DISCUSSION
Our results suggest that deprescribing interventions should focus on communication and address systemic barriers that impede communication between clinicians, pharmacists, and patients. The most frequently identified clinician and pharmacist barriers to deprescribing were related to communication with other healthcare providers and insufficient time with patients to discuss deprescribing. Similarly, adequate time for quality discussions with patients was identified as a top three facilitator by both clinicians and pharmacists, and pharmacists reiterated the importance of being able to communicate directly with healthcare providers about deprescribing. Previous studies reported that communication gaps between clinicians, patients, and pharmacists create barriers to deprescribing.8
A successful deprescribing intervention will need to address interpersonal trust between clinicians, pharmacists, and patients. Patients are more likely to accept deprescribing recommendations when they trust the healthcare provider who makes the recommendation.9 Development of trust between patients, clinicians, and pharmacists is a complex process that builds on the perception of many behaviors, including communication.10 To succeed, deprescribing interventions need basis in behavioral change models and communication theories that emphasize building trust between the involved parties.
ACKNOWLEDGEMENTS
We would like to thank Kentucky Ambulatory Network, Kentucky Academy of Family Physicians, Center for the Advancement of Pharmacy Practice/Advancing Pharmacy Practice, and Kentucky Pharmacist Association for permitting us to use their listservs for recruitment. We would also like to thank Amy Linsky MD, MSc for her review and contributions.
Financial Disclosure:
The project was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Sponsor’s Role:
The content is solely the responsibility of the authors.
Footnotes
Conflict of Interest: The authors have no conflicts.
Availability of Materials: The surveys used in this study can be made available upon reasonable request to the corresponding author.
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