Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences

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):192-198Takeaway 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]).

Survey Administration

We mailed subjects a letter introducing the survey objectives and informing them of its upcoming arrival. One week later, we mailed the 12-page survey instrument, a $5 incentive, and an opt-out postcard. Nonrespondents received a reminder letter 2 weeks later, and a second survey was sent to remaining nonrespondents after 2 additional weeks. Subjects who could not be contacted (mail undeliverable or notification received of their death) were removed from the administration cycle.

Measures

Primary outcome. Our primary outcome variable was a measure of relative deprescribing authority (RDA), defined as the extent to which patients afforded different providers the authority to discontinue a medication prescribed by another provider. The measure was derived by combining responses to 2 yes/no (Y/N) items: (1) “Imagine that a specialist…prescribed a medicine for you. Would you be comfortable if your PCP told you to stop taking it?” and (2) “Imagine that your VA PCP prescribed a medicine for you. Would you be comfortable if a VA clinical pharmacist told you to stop taking it?” We created 4 distinct categorical RDA outcome groups: PCP-N/Pharm-N, PCP-N/Pharm-Y, PCP-Y/Pharm-N, and PCP-Y/Pharm-Y, where PCP or Pharm (pharmacist) indicates the provider of interest and Y/N indicates whether the respondent felt that that provider had the jurisdiction to recommend stopping medications prescribed by a provider higher in the prescribing authority hierarchy. This categorization is described in the Figure (A). VA clinical pharmacists have prescribing authority and may manage patients with chronic conditions.

Predictor variables. Our primary predictors of interest were the 8 attitudinal scales of the PPoD survey instrument. Secondary predictors included patient characteristics and experiential variables (ie, items about whether the patient had ever asked their doctor to stop a medicine; had seen a VA PCP, VA specialist, and/or VA clinical pharmacist in the past year; had ever received conflicting advice from different providers; and had ever been told to stop a medicine).

Analysis

We verified data validity by examining item frequencies, correcting out-of-range values, and adjusting contradictory response patterns for items involving screener questions or other contingencies. We conducted bivariate tests of association (χ² tests and t tests as applicable) between all patient characteristic and attitudinal scale variables and the 4 categorical RDA primary outcome groups. Variables with associations significant at the P <.1 level were retained for inclusion in a multinomial logistic regression to determine which factors are associated with each of the 4 categorical outcome groups; a stepwise approach was used to obtain the most parsimonious model. Our null hypothesis was that there are no differences in patient characteristics or attitudes among the 4 RDA outcome groups.

All analyses were conducted in SAS version 9.3 (SAS Institute Inc; Cary, North Carolina). The study was approved by the VA Boston Healthcare System Institutional Review Board.

RESULTS

Characteristics of Study Sample

Of the 1600 veterans in the mail-out sample, 53 were unreachable. We obtained 803 surveys, for an adjusted response rate of 52%. Nonrespondents were similar to respondents with regard to race and region of the country, but respondents were older (mean age, 67.0 vs 65.5 years; P = .01) and took slightly fewer medications (mean, 10.1 vs 10.5; P = .02).

Respondents were predominantly men (85%); 68% identified as non-Hispanic white and 17% as non-Hispanic black (Table 1 [part A and part B]). The majority (60%) were older than 65 years, with generally poor (16%) or fair (45%) health. With respect to prescriptions, 6% reported taking fewer than 5, 38% reported 5 to 8, 35% reported 9 to 12, and 21% reported 13 or more prescriptions.

Participant attitudes toward medications and their providers were generally favorable (Table 2). Respondents generally disagreed that medicines were either unimportant or overused, with mean scores of 2.39 and 2.91 on the Unimportance of Medicine and the BMQ—Overuse scales, respectively. Respondents held generally positive views of providers, with mean scores of 3.75 on Provider Knowledge and 3.56 on Trust–provider. Concurrently, patients were generally interested in stopping medicines (mean, 3.42).

Subjects had varied experiences related to deprescribing communication and decisions (Table 3). Fewer than 1 in 5 patients (18%) reported receiving conflicting medication information from different providers. More than half (53%) recalled being told by a provider to stop a medicine, and a similar proportion (55%) reported that they had asked their doctor to stop a medicine. Just over 1 in 3 patients (34.1%) reported actually having stopped a medicine.

Respondent Preferences and Predictors of RDA

A total of 735 respondents answered both questions that were used to create the RDA outcome measure. As summarized in the Figure (B), 281 (38%) were uncomfortable with both a PCP stopping a specialist-prescribed medication and a clinical pharmacist stopping a PCP-prescribed medication (PCP-N/Pharm-N). In contrast, 146 (20%) indicated that they would be comfortable with both a PCP stopping a specialist-prescribed medication and a clinical pharmacist stopping a PCP-prescribed medication (PCP-Y/Pharm-Y). There were 155 (21%) who said no to the PCP stopping a specialist’s medication and yes to the clinical pharmacist stopping a PCP’s medication (PCP-N/Pharm-Y), whereas 153 (21%) said yes to the PCP’s authority but no to the clinical pharmacist’s (PCP-Y/Pharm-N).

Based on bivariate analyses (data not shown), variables initially included in the multinomial logistic regression model predicting RDA outcome groups were self-reported diagnosis of chronic lung disease, depression, heart failure, or ischemic heart disease; number of prescriptions; seeing a non-VA specialist; receiving conflicting advice; being told to stop a medicine; marital status; and 6 attitudinal scales (BMQ, Trust—provider, CollaboRATE, Medication Concerns, Provider Knowledge, and Patient Involvement in Decision Making).

In the final model, when setting the group who responded no to both questions as the reference (PCP-N/Pharm-N), several factors influenced the likelihood of being in 1 of the other 3 RDA groups (Table 4). Specifically, those with a diagnosis of chronic lung disease were less likely to be in the PCP-Y/Pharm-N group (odds ratio [OR], 0.52; 95% CI, 0.31-0.88). Those indicating higher trust in their PCP were less likely to be in the PCP-N/Pharm-Y group (OR, 0.52; 95% CI, 0.34-0.81) but more likely to be in the PCP-Y/Pharm-N (OR, 2.16; 95% CI, 1.31-3.56) or PCP-Y/Pharm-Y groups (OR, 1.83; 95% CI, 1.13-2.98). Patients with greater concerns about medication were more likely to be in the PCP-Y/Pharm-Y group (OR, 1.45; 95% CI, 1.09-1.92). Veterans interested in being involved in decision making about medicines were more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04-1.92).

DISCUSSION

We conducted a national survey to assess patients’ preferences for and attitudes toward different providers discontinuing their medications. Our primary outcome measure of RDA characterizes 4 patient groups based on their willingness to allow clinicians to discontinue medications prescribed by other clinicians. Whereas some patients were willing to allow any provider to deprescribe, others were uncomfortable accepting such recommendations from providers with different levels of expertise. Variation in patient preferences may be reflected in each of the 4 RDA groups.

In our study, the most common RDA group was PCP-N/Pharm-N, with 38% of respondents indicating that they would not want their PCP to discontinue a medication prescribed by a specialist, nor would they want a clinical pharmacist to discontinue a medication prescribed by the PCP. These patients may place greater value in specialists’ increased training and expertise and thus grant them preferential jurisdiction over all decisions related to their specialty.²⁴ However, this preference might not always be realistic in the current healthcare environment in which patients often receive care from multiple providers.⁹ Patients may also feel that the original prescriber should maintain authority because of concerns that another clinician lacks the information required to make a medically sound deprescribing recommendation.²⁵ This reluctance may be justified given that having multiple providers can be a safety concern⁹ and optimal coordination among PCPs and specialists often remains elusive. Improving communication among clinicians could alleviate this potential patient concern.

At the other end of the spectrum, patients who are comfortable with both their PCP and a clinical pharmacist deprescribing a medication prescribed by someone with more expertise (PCP-Y/Pharm-Y; 20%) may generally prefer fewer medications, welcoming any opportunity to reduce their number. Respondents with greater medication concerns were more likely to be in this group and thus may be more proactive in asking providers about stopping medicines. Efforts to reduce overmedication can capitalize on this patient characteristic, and activating the patient to question the continued need of a medication can lead to discontinuation attempts.²⁶ Patients who are more amenable to anyone discontinuing their medications may also demonstrate greater nonadherence to their prescriptions, and streamlining their medication regimens may improve adherence.²⁷

The 2 discordant RDA groups fall somewhere in the middle. Patients comfortable with the PCP discontinuing a specialist’s medication but not with the clinical pharmacist making the same recommendation (PCP-Y/Pharm-N; 21%) may view their PCP as having ultimate responsibility for their care, with final decision-making authority. This attitude may result from trust, confidence in the PCP’s medical knowledge, familiarity with their PCP, or concerns about needing 1 provider to oversee everything.^25,28,29 In our study, patients with chronic lung disease were less likely to respond PCP-Y/Pharm-N, perhaps reflecting that they may regularly see a specialist (eg, a pulmonologist) for this condition, which leads patients to not want the PCP to change the specialist’s medications.

The other discordant RDA outcome group has the opposite response pattern, with patients unwilling to allow the PCP to discontinue a specialist’s medication but amenable to a clinical pharmacist deprescribing a PCP’s medication (PCP-N/Pharm-Y; 21%). Several factors in a patient—provider relationship influence the level of trust in a particular provider, such as duration, gender and/or racial concordance, provider level of expertise, or other intangible qualities,^30-32 ultimately affecting whether a patient is comfortable with the PCP deprescribing a specialist’s prescription.

Other possible reasons for the PCP-N/Pharm-Y pattern focus on the pharmacist. Patients may view the clinical pharmacist as an extension of the PCP, acting as part of the Patient-Aligned Care Team (the VA’s patient-centered medical home) with prescribing authority on par with PCPs. In a survey of older Canadian adults, 51% were comfortable, 25% unsure, and 19% uncomfortable with pharmacists having a role in deprescribing.³³ In comparison, our study had fewer patients reporting comfort with clinical pharmacists deprescribing, but this may result from not explicitly stating that PCPs would be informed of decisions; doing so may have reassured the respondent. Another potential explanation for patients’ comfort with clinical pharmacists deprescribing may be related to the nature of their interactions, such as spending more time together reviewing patients’ medications and their indications, as well as discussing strategies for medication adherence. Patients with more interest in participating in medication-related decision making were more likely to be in this PCP-N/Pharm-Y group, reflecting that interactions with pharmacists may afford more opportunity for patients to express their wishes.

Our findings have multiple implications for safe and appropriate medication deprescribing. An overarching theme is that for the many patients who receive care from multiple providers, whether within or across healthcare systems, coordination and communication among providers is essential, and many patients assume this occurs regularly and efficiently. However, given the known difficulties associated with reliance on the electronic health record to accomplish this coordination,^34,35 as well as providers’ perception that more communication is needed,³⁶ communication systems need to be developed and implemented to reduce the risks associated with having multiple prescribers. Further, efforts to develop deprescribing clinics, which may introduce another clinician into the patient’s care, should recognize patient interest and comfort in knowing that their providers are communicating with one another.

The frequency and quality of professional communication may also influence clinicians’ perception of the scope of their deprescribing jurisdiction. One possibility is that clinicians’ discomfort with or potential unwillingness to take on the additional workload associated with deprescribing is unintentionally imparting these same hierarchical views to patients. Efforts to increase the confidence of all clinicians to practice at the top of their license may improve the frequency with which deprescribing recommendations are made and increase the trust patients place in clinicians of all training to provide high-quality and high-value treatment.

As clinical pharmacists expand their scope of practice, many have advocated for their integration into varied care settings, broadening the benefit they provide.^37,38 Inclusion of pharmacists on teams can lead to more appropriate medication use and fewer adverse drug events.³⁹ Specific to the focus of our study, Twigg et al found that pharmacists often identify medications that are appropriate to deprescribe.⁴⁰ However, in that study, pharmacists only made recommendations; they did not enact the decisions. With the expansion of prescribing—and thus deprescribing&mdash;authority to pharmacists, it will be important to ensure that they feel empowered to enact decisions; that other clinicians “higher” in the prescribing hierarchy do not feel undermined by such actions; and, just as critically, that patients are receptive to receiving such recommendations from pharmacists. Our study provides support for an expanded pharmacist role, with a substantial percentage of patients expressing comfort with pharmacists managing their medications.

Limitations

Our study is not without limitations. We surveyed veterans actively using the VA healthcare system, and results may not generalize to non-VA settings. These participants were predominantly men, and gender differences may influence healthcare attitudes. Also, veterans’ experience with the military hierarchy may influence their attitudes as patients in any medical system; a civilian population may respond differently. However, research within community settings has shown that patients ascribe different roles and responsibilities to clinical team members (eg, specialist, PCP, pharmacist, nurse), in essence creating hierarchies.³³ It is also possible that the national health system of the VA, including a single electronic health record, leads patients to believe that their care is more coordinated than elsewhere. Nonetheless, many veterans use both VA and non-VA care and remain subject to the same gaps in communication that happen for nonusers of the VA. Another potential limitation to the generalizability of our findings is that clinical pharmacists within VA have a scope of practice whereby they can prescribe, monitor, and perform other activities to facilitate patient care. Pharmacists in non-VA settings may or may not be empowered to perform these activities, depending on the terms of their collaborative practice agreements. Regardless, implementation of medical homes nationally will require all team members to work at the top of their license, and thus findings within VA are relevant elsewhere. Finally, the survey questions were asked in a hypothetical and general manner; it is possible that patients would respond differently in actual clinical scenarios with specific medications. Additional work examining outcomes from clinical encounters should be conducted.

CONCLUSIONS

Inappropriate medication use places patients at risk of harm, burdening patients and the healthcare system. Efforts to improve the rational use of medicine should include support for deprescribing, but if patients are unwilling to accept recommendations to stop a medication from a particular provider, these efforts will fail. Moreover, because deprescribing could be considered a “preference-sensitive decision,”⁴¹ incorporating patient attitudes and preferences about medications may also mitigate clinicians’ concerns about patient resistance to deprescribing.^11,42 Understanding patient preferences related to medication prescribing and attitudes toward RDA can ultimately facilitate effective design and implementation of deprescribing interventions.

Acknowledgments

The authors thank Rachel Lippin-Foster, BA, for her assistance in the management of the survey.Author Affiliations: Section of General Internal Medicine (AL), Center for Healthcare Organization and Implementation Research (CHOIR) (AL, KS, SRS), and Geriatrics and Extended Care (SRS), VA Boston Healthcare System, Boston, MA; Section of General Internal Medicine, Boston Medical Center (AL), Boston, MA; Veterans Health Administration Office of Reporting, Analytics, Performance, Improvement and Deployment (MM), Bedford, MA; Department of Health Law, Policy & Management, Boston University School of Public Health (MM, BGB), Boston, MA; CHOIR, ENRM Veterans Affairs Medical Center (BGB), Bedford, MA.

Source of Funding: This study was funded by VA Health Services Research & Development (CDA 12-166), which had no role in the study’s design and conduct; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; nor decision to submit the manuscript for publication.

Prior Presentation: This study was presented in poster format at the Society for General Internal Medicine Annual Meeting in Washington, DC (April 2017), and at the AcademyHealth Annual Research Meeting in New Orleans, LA (June 2017), as well as in oral format at the Lown Conference in Boston, MA (May 2017).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AL, MM, SRS); acquisition of data (AL, KS); analysis and interpretation of data (AL, MM, BGB, KS); drafting of the manuscript (AL); critical revision of the manuscript for important intellectual content (AL, MM, BGB, SRS); statistical analysis (AL, KS); obtaining funding (AL, BGB); administrative, technical, or logistic support (AL, SRS); and supervision (SRS).

Address Correspondence to: Amy Linsky, MD, MSc, Section of General Internal Medicine (152G), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130. Email: amy.linsky@va.gov.REFERENCES

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