# Physicians' views on pharmacists' involvement in hospital deprescribing: A qualitative study on proton pump inhibitors

Pauline Gendre, Séverine Mayol, Julie Mocquard, Jean-François Huon

► To cite this version:

Pauline Gendre, Séverine Mayol, Julie Mocquard, Jean-François Huon. Physicians' views on pharmacists' involvement in hospital deprescribing: A qualitative study on proton pump inhibitors. Basic and Clinical Pharmacology and Toxicology, 2023, 133 (6), pp.718 - 728. 10.1111/bcpt.13878. hal-04459061

HAL Id: hal-04459061

https://nantes-universite.hal.science/hal-04459061v1

Submitted on 15 Feb 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
ORIGINAL ARTICLE

BCPT
Basic & Clinical Pharmacology & Toxicology

# Physicians' views on pharmacists' involvement in hospital deprescribing: A qualitative study on proton pump inhibitors

Pauline Gendre<fnref n="1" /> | Severine Mayol<fnref n="2" /> | Julie Mocquard<fnref n="1" /> | Jean-François Huon<fnref n="1" />,<fnref n="3" /> ID

**Correspondence**

Jean-François Huon, CHU Nantes, Pharmacy Department, Nantes University, Nantes, France.
Email: jeanfrancois.huon@chu-nantes.fr

**Funding information**

None.

**Abstract**

**Background:** Clinical pharmacists have a pivotal role in the management of the patient's medication. However, it is necessary to know how pharmacist-mediated deprescribing could be implemented in a hospital setting according to hospital physicians.

**Objective:** To explore physicians' views on the involvement of hospital pharmacists in the deprescribing process using the example of PPIs.

**Methods:** A qualitative study using two focus groups with hospital physicians was conducted to determine their attitudes regarding deprescribing initiated by the hospital pharmacist. The interviews were recorded and transcribed using the NVivo analysis software. A thematic analysis led to a categorization of all the verbatims.

**Results:** Hospital doctors are reluctant to deprescribe drugs initiated by a colleague and feel that it is the responsibility of the general practitioner (GP), who fails to do so due to lack of time. In this situation, the hospital pharmacist is in the best position to deprescribe because of his/her expertise in drug therapy. This should be a discussion between the hospital pharmacist, the hospital doctor, the GP and the patient. Deprescribing should always be adapted to the patient's context.

**Conclusion:** Hospital physicians are open to a pharmacist-mediated, patient-centred approach to deprescribing as long as the GP is involved.

**KEYWORDS**

clinical pharmacy, deprescribing, hospital setting, proton pump inhibitors, qualitative research

## 1 | INTRODUCTION

Deprescribing is defined as stopping or reducing a drug or switching to another therapeutic class of a treatment that may cause harm or no longer provide benefit.<fnref n="1" /> The

goal of this procedure is to reduce the drug burden and iatrogenicity while maintaining or improving quality of life. However, deprescribing can be difficult, especially when medications do not appear to cause symptomatic adverse effects. Indeed, a patient may be more likely to

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

© 2023 The Authors. Basic & Clinical Pharmacology & Toxicology published by John Wiley & Sons Ltd on behalf of Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

<footnote n="1">¹CHU Nantes, Pharmacy Department, Nantes University, Nantes, France</footnote>

<footnote n="2">²Faculty of Sociology, Nantes University, Nantes, France</footnote>

<footnote n="3">³INSERM, MethodS in Patients-centered outcomes and Health Research, SPHERE, Nantes, France</footnote>
discontinue an antidepressant because of a decrease in
libido than a proton pump inhibitor because of a risk of
osteoporosis. Pharmacists are well positioned to over-
come these challenges and facilitate drug deprescribing.
Clinical pharmacy is an aspect of the pharmacy profes-
sion aimed at the development and promotion of appro-
priate, safe and economical use of health products.²
Among other activities, the re-evaluation of treatments
and their prescription is part of a therapeutic optimiza-
tion process that involves several health professionals,
including the pharmacist.

Proton pump inhibitors (PPIs) are very commonly
prescribed for adults in many countries,³⁻⁶ especially for
the elderly.⁷ However, for more than a decade, they have
been incriminated in the occurrence of adverse effects,
which, on the scale of a population highly exposed to
these drugs, can become significant in terms of public
health.⁸ PPI use continues to grow every year in almost
every country,⁹ but it would be less of a problem if more
than 50% of PPIs prescription were not inappropriate,¹⁰
sometimes up to 84%.¹¹ When prescribing PPIs, as with
any other medication, the benefit/risk balance of its
administration must be assessed at every stage of the
treatment. Thus, the proper use of any medication
includes respecting the indications, adjusting the dosage
to the minimum effective dose and re-evaluating the
treatment with each new prescription, with the aim of
limiting the occurrence of adverse effects. This reassess-
ment may lead to the discontinuation of the treatment if
it is identified as inappropriate. The peer-reviewed jour-
nal *Cochrane* published an article in 2017 discussing the
benefits and harms associated with deprescribing long-
term PPIs.¹² This review identifies several barriers to the
deprescribing of these drugs¹³: physicians' beliefs (safety
of PPIs, difficulty in modifying a treatment initiated by a
colleague, lack of guidelines for deprescribing or fear of
rebound effects), workload or pressure exerted by
patients (desire to obtain a medical prescription on leav-
ing the consultation). This highlights that although spe-
cific guidelines for PPI deprescribing have been
published, along with materials for patients and health-
care professionals,¹⁴ implementation of this process
remains a challenge today.

Thus, the implementation of a joint hospital
physician-clinical pharmacist intervention would make
it possible to reduce inappropriate prescriptions and to
maintain over time a coordinated interprofessional action
in order to ensure better patient safety.¹⁵ Indeed, inter-
professional collaboration is defined by the World Health
Organization as a learning process and an activity that
takes place when specialists from two or more profes-
sions work together. They learn from each other in the
sense of effective collaboration that leads to improved

health outcomes.¹⁶ Studies have shown that collaboration
between community pharmacists and primary care physi-
cians, centred around adherence management, is possible
and improves the long-term management of patients with
chronic diseases.¹⁷ This type of collaboration has not yet
been evaluated in a hospital setting and could be
extended to the various stages of patient care
management.

The main objective of our study was to explore hospi-
tal physicians' perception on the involvement of clinical
pharmacists in the deprescribing process using the exam-
ple of PPIs. We sought to identify barriers and motiva-
tions for physician deprescribing and to explore how
physician knowledge and confidence in the work of the
hospital pharmacist may influence their collaboration
and deprescribing. These aims were achieved through a
qualitative methodology.

2 | MATERIALS AND METHODS

A single-centre qualitative study was conducted at the
University Hospital of Nantes, France, in April 2021.
Additionally, the Consolidated Criteria for Reporting
Qualitative Research (COREQ) checklist¹⁸ guided the
reporting in this study (Data S1). The study has been per-
formed in accordance with the BCPT policy for experi-
mental and clinical studies.¹⁹

2.1 | Participants and recruitment

Physicians were recruited from the medical staff of the
institution and contacted directly. They were recruited by
email and telephone from the institution's medical teams.
Snowball sampling was done by asking the participants
to suggest their peer specialists for participation.
Reminders were generated until a sufficient number of
physicians were reached. Two groups were created: the
first consisting of 10 physicians working in departments
without a clinical pharmacy team (Group 1) and the sec-
ond of 10 physicians working in departments with a clini-
cal pharmacy activity already in place (Group 2), the
latter being aware of clinical pharmacy activities. No
other inclusion criteria were added. Some participants
may have previously worked with the investigators and
be familiar with their activities as clinical pharmacists.
Pragmatically, as hospital doctors from different disci-
plines were difficult to bring together at the same time,
and knowing that two to three focus groups are sufficient
to capture 80% of the codes,²⁰,²¹ acceptable code satura-
tion was considered obtained with these two focus
groups. After information about the study and a
guarantee of anonymity, written consent was obtained from the participating physicians. Participation was free and not subject to any form of compensation.

## 2.2 | Data collection

The study was conducted using the focused interview or ‘focus group’ method to determine the responses and attitudes adopted by the physicians interviewed regarding deprescribing, based on targeted cases on PPIs.²²,²³ This method allows for the collection of in-depth information in a relatively short period of time. It enables for a detailed examination of how the group members think and feel about the subject. The type of data generated by the social interaction of the group is often deeper and richer than that obtained in individual interviews.²⁴ Thus, based on two practical cases of deprescribing initiated by the hospital pharmacist, it was asked to respondents to express their ideas and beliefs (Data S2). No theoretical framework was used. The vignettes method was favoured to encourage discussion of cases by avoiding some peer effects (two participants who know each other talking about a common situation) and to allow participants to more easily discuss familiar but fictional situations, as described in the literature.²⁵,²⁶ In accordance with the ‘focus group’ principle, spontaneous questioning was favoured instead of formalized and explicit open questions. The focus groups were held within the hospital in a room set up for the occasion. The first author was the main facilitator of the interview. She was trained to conduct an interview beforehand during simulation sessions and was then given an interview guide (Data S3) with open-ended questions if the need arose to refocus the exchanges. This interview guide was piloted and validated with two people beforehand (a physician and a pharmacist, both not involved in the study). In the first case studied, the scenario was such that the pharmacist took the personal initiative to deprescribe without informing the physician first. In the second scenario, the physician objected to the pharmacist’s proposed deprescribing. The facilitator was supported by two co-facilitators (third and last author) trained in qualitative research and interviewing. They ensured that each participant’s experience and opinion could be explored during the session. The focus groups were conducted in French, and no non-participants were present during the interview.

The overall methodology, as well as the interview guide, were jointly produced and validated by the second author, a methodologist with a doctorate in sociology, specialized in qualitative analysis within the hospital. The interviews were recorded by voice recorder and were

to last as long as necessary for the respondents to express themselves fully.

## 2.3 | Ethical considerations

Our study was approved by the local Group of Ethics in Health on 1 March 2021 (IRB GNEDS 20210301), and all physicians provided written informed consent prior to enrolment in the study.

## 2.4 | Data analyses

The interviews were transcribed using the qualitative analysis software NVivo® (V.12.7.0) immediately after each session and were then completely anonymized. A phenomenological design was used to explore the perceptions. The qualitative analysis was carried out by the first, third and last authors using the six-step thematic analysis by Braun and Clarke.²⁷ Briefly, it consisted of categorization and thematization of all the verbatims from each group through systematic inductive coding. The results of the two groups were analysed independently. The verbatims were categorized into sub-themes and then into themes. The themes from each of the two groups were then pooled and rearranged to ensure coherence, and quotes were extracted to better illustrate the themes.²⁸

# 3 | RESULTS

Of the 20 physicians approached, 12 (five in Group 1 and seven in Group 2) agreed to participate in the focus groups and gave their consent. The physicians who refused to participate justified their refusal by a lack of time or interest. The two interviews lasted 80 and 85 min, respectively, and took place at the University Hospital in Nantes in April 2021. The complete transcript of the focus groups can be found in Data S4.

The first group consisted of three women and two men: a nephrologist, two paediatricians, an infectious disease specialist and an emergency physician, aged 30–42 years. The second group consisted of one woman and six men: two digestive surgeons, one orthopaedic surgeon, one urologist, one maxillofacial surgeon and two anaesthesiologists, aged 28–34 years.

After analysis, five major categories were identified (Figure 1):

* motivations and barriers to deprescribing,

* intra-hospital interprofessionality and its influence on deprescribing,
<figure><img src="image_2.png" /><figcaption>FIGURE 1 Main themes identified.</figcaption></figure>

* out-of-hospital interprofessionality and its influence on deprescribing,

* the proposed implementation of deprescribing,

* patient-centred personalized medicine.

## 3.1 | Motivations and barriers to deprescribing

It was agreed by all physicians that deprescribing was essential and necessary. They felt that this deprescribing was justified because of the very high socioeconomic cost of drug misuse, particularly of PPIs, and the false sense of safety involved (Table 1, **a1 and a2**).

In their view, deprescribing could initially focus on the most at-risk patients, identified as elderly, polypathological patients. It was in this population that deprescribing would be the most difficult, but also the most important and necessary (Table 1, **a3 and a4**). However, PPIs were not considered as the most important drug class to deprescribe first (Table 1, **a11**).

Concerning the obstacles to deprescribing, the participants mainly mentioned the lack of time to carry it out and to explain the approach to the patient (Table 1, **a5-a7**). They also noted a reluctance to stop a treatment started by a colleague (Table 1, **a8**), as they did not feel legitimate to do so, or were sometimes unaware of the indications of the treatment, particularly for drugs outside their area of specialization (Table 1, **a9 and a10**). Routine renewal of a drug prescription without questioning its appropriateness was therefore described as the easiest solution by most of the respondents, reinforced

by the computerization of healthcare, which facilitates one-click renewal.

## 3.2 | Intra-hospital interprofessionality and its influence on deprescribing

The interviews revealed that physicians had a positive image of the hospital pharmacist (Table 2, **b1**): The technical expertise of the hospital pharmacist reinforces the physician's practice, thus saving time (Table 2, **b2**), thanks to a detailed analysis of the prescription and drug interactions (Table 2, **b3 and b4**).

Nevertheless, the physicians admitted that they were in all cases responsible for the patient's prescription. Moreover, the pharmacist was described as not necessarily the most competent to judge the indications, not knowing all the pathologies and not having the 'real life' experience to best advise the physicians in their therapeutic orientation (Table 2, **b5**). According to the respondents, the pharmacist should remain transversal and not specialize in a particular field: he or she should know all aspects of the patient's drug management.

Group 1 subjects expressed concern about the lack of interest in deprescribing by their fellow surgeons and anaesthesiologists. They felt that it would be difficult to have deprescribing adopted in surgical departments. Surgeons were indeed physicians, but their specialty took them far away from drug management (Table 2, **b6**). The surgeon's goal was not to manage chronic treatments (Table 2, **b7**), and the anaesthesiologists were overworked and did not have the time to carry out deprescribing in good conditions (Table 2, **b8**). Collaboration leading to
<table><caption>TABLE 1 Verbatims for the category ‘Barriers and motivation to deprescribe’.</caption><thead><tr><th colspan="3">Barriers and motivation to deprescribing</th></tr><tr><th>Themes</th><th>Main sub-themes</th><th>Units of meaning</th></tr></thead><tbody><tr><td rowspan="4">Motivations for deprescribing</td><td>Awareness of the socio-economic cost of PPI</td><td>a1 'it's clear that it's a public health and economic problem'</td></tr><tr><td>Feeling of false safety with this class</td><td>a2 'we have a false impression typically on this thing that there is a perfect harmlessness, whereas it is false'</td></tr><tr><td>Priority target population</td><td>a3 'the polymediates'<br>a4 'the oldest polypathologists. But that's where it's going to be most difficult'</td></tr><tr><td>Lack of time</td><td>a5 'it's an easy solution to turn a blind eye to it'</td></tr><tr><td rowspan="7">Barriers to deprescribing</td><td>Ease of prescription renewal</td><td>a6 'it takes longer to explain why we stop'</td></tr><tr><td>Having to justify your actions</td><td>a7 'it's true that we don't take the time to review the usual treatment'</td></tr><tr><td>There must be a reason behind every prescription</td><td>a8 'If it's prescribed, it's always right'</td></tr><tr><td>Lack of knowledge about the medication—fear of stopping treatment</td><td>a9 'I don't touch the medicine I don't know'</td></tr><tr><td>Lack of knowledge of treatments outside the physician's specialty</td><td>a10 'I think it would be inappropriate for the urologist to make suggestions for changes in the patient's usual treatments'</td></tr><tr><td>Do not prioritize PPIs</td><td>a11 'PPI is your fight'</td></tr></tbody></table>

Notes: Group 2, physicians practising in departments with an existing clinical pharmacy activity. Group 1, physicians practising in departments without a clinical pharmacy team.

<table><caption>TABLE 2 Verbatims for the category ‘Intra-hospital interprofessionality and its influence on PPI prescription’.</caption><thead><tr><th colspan="3">Intra-hospital interprofessionality and its influence on the deprescription of PPIs</th></tr><tr><th>Themes</th><th>Main sub-themes</th><th>Units of meaning</th></tr></thead><tbody><tr><td rowspan="4">Physician/pharmacist relationship</td><td>Positive image of the pharmacist—trusted by the physician</td><td>b1 'I trust the pharmacist'</td></tr><tr><td>It helps and saves time</td><td>b2 'but probably we all stand to gain from having a pharmacist on our ward'</td></tr><tr><td>He is well aware of drug interactions—more efficient than a GP in 'cleaning' prescriptions</td><td>b3 'but in my opinion [the pharmacist is] much better than a GP'</td></tr><tr><td>Cannot prescribe—physician remains responsible for prescribing—no 'life' experience</td><td>b4 'I think you do 10 times the job on cleaning up ordinances'</td></tr><tr><td rowspan="3">Relationship between physicians</td><td rowspan="3">Difficulty of deprescribing in surgical wards because the surgeon is not interested in the drugs</td><td>b5 'There are theoretical MA indications and even after real life, real life. I think that's very important in a medical decision. Real life, it takes precedence'</td></tr><tr><td>b6 'I think that between surgery and medicine .... It's a world'</td></tr><tr><td>b7 'The surgeon, he operates. He is not there to manage drug interactions'</td></tr><tr><td></td><td></td><td>b8 'The anaesthetists have other things to do. They're overworked'</td></tr></tbody></table>

Notes: Group 2, physicians practising in departments with an existing clinical pharmacy activity. Group 1, physicians practising in departments without a clinical pharmacy team.
deprescribing was therefore variable by department and by physician specialty. The participants in Group 2 had a positive interest in the subject and were not opposed to this collaboration.

## 3.3 | Out-of-hospital interprofessionality and its influence on deprescribing

The respondents' view of interprofessional relations was marked by a distinction between hospital and outpatient medicine. Indeed, the hospital seemed to be the right place to re-evaluate chronic treatment because the patient remained hospitalized for several days. The academic context in a public hospital was described as particularly facilitating openness to discussion (Table 3, c1). Deprescribing in hospital was considered to be done in a controlled and secure environment to limit the occurrence of potential adverse withdrawal events following discontinuation of treatment. On the other

hand, it challenged the place of the hospital in the management of chronic treatments, which was not part of its mission outside of an acute episode (Table 3, c4). The respondents considered it inappropriate to change a chronic treatment during an episode of hospitalization, which was a source of significant stress. Hospital practitioners also felt that such a practice could be responsible for an increase in the average length of stay in hospital, which was not compatible with current health policy (Table 3, c3).

Following the questioning of the hospital's role, the two groups discussed the general practitioner's (GP) role and agreed that deprescribing should normally be his responsibility (Table 3, c5). However, it was noted that most of the time, the GP did not carry out this mission due to lack of time or energy. Indeed, this required a real involvement of the prescriber in order to follow up potential withdrawal or rebound effects following the deprescribing. The GP could not be familiar with all the pathologies, the indications for treatment and their

<table><caption>TABLE 3 Verbatims for the category 'Out-of-hospital interprofessionality and its influence on PPI prescription'.</caption><thead><tr><th colspan="3">Out-of-hospital interprofessionality and its influence on PPI prescription</th></tr><tr><th>Themes</th><th>Main sub-themes</th><th>Units of meaning</th></tr></thead><tbody><tr><td rowspan="4">Role of the hospital in deprescribing</td><td>The hospital is the right place to review the patient's chronic treatment because the patient stays for several days so there is time and there are competent people</td><td>c1 'But it's a good time to sort it out because we have people who are good at it'</td></tr><tr><td>Questioning the doctrine of cost reduction in the hospital</td><td>c2 'at least we know it's done'</td></tr><tr><td>But this calls into question the role of the hospital and the management of chronic treatment</td><td>c3 'We are trying more and more to have lengths of stay that are as short as possible. So, if in the acute pathology, we have to integrate all this...'</td></tr><tr><td>The deprescribing should normally be made by the GP</td><td>c4 'Is it the function of the hospital to manage the chronic treatment of patients when they have an intercurrent acute episode?'</td></tr><tr><td rowspan="6">Role of the GP in deprescribing</td><td>But he does not do it for several reasons: He does not have the time; he does not know all the pathologies and treatments</td><td>c5 'this should be a GP's job'</td></tr><tr><td>However, the physician must be included in the discussion of PPIs because he or she knows the patient best and generally knows the initial indication</td><td>c6 'And I do not think the treating physicians have the time to do that or the energy'</td></tr><tr><td>Risk of deteriorating relationships between community and healthcare institutions professionals</td><td>c7 'The general practitioner is already supposed to know almost all the pathologies, but on top of that, he has to know the specificities of all the treatments. Finally, it's just impossible'</td></tr><tr><td>It remains the guy who, in theory, knows his patient best</td><td>c8 'it remains the guy who, in theory, knows his patient best'</td></tr><tr><td>The relationship can be strained if we start slashing each other's prescriptions</td><td>c9 'Their relationship can be strained if we start slashing each other's prescriptions'</td></tr><tr><td>If there's no info and there's no reason, people will take it the wrong way</td><td>c10 'if there's no info and there's no reason, people will take it the wrong way'</td></tr><tr><td colspan="2"></td><td>c11 'A suggestion to stop, I think it's communication'</td></tr></tbody></table>

Notes: Group 2, physicians practising in departments with an existing clinical pharmacy activity. Group 1, physicians practising in departments without a clinical pharmacy team.
specificities. On the other hand, the respondents admitted that he should be included in the deprescribing process. Indeed, it was the GP who knew the patient best and who could also know the initial indication for the treatment (Table 3, c6). The potential risk of deteriorating relationships between healthcare professionals within the community and healthcare institutions due to inadequate communication was a topic of discussion. GPs may not understand why the hospital would interfere with their patient's chronic treatments (Table 3, c9). Sufficient and appropriate communication between the hospital, the patient and the GP was therefore essential for successful deprescribing (Table 3, c10).

## 3.4 | The proposed implementation of deprescribing

Concerning the envisaged implementation of deprescribing, five themes were mentioned by the respondents: actors, format, temporality, tools and financial means.

The pharmacist was considered the most legitimate professional to implement deprescribing (Table 4, d1). Physicians were unanimous on the form that deprescribing should take. For them, the pharmacist should make a recommendation to the medical team without overstepping his or her advisory role (Table 4, d2). This should result in a shared decision between the physician, the pharmacist and the patient.

Opinions were divided as to the most appropriate time to deprescribe during hospitalization. For some, it should be done at the beginning of the hospitalization to allow monitoring of the patient's tolerance to the cessation of treatment (Table 4, d7). On the other hand, for others, the deprescribing should take place at the end of hospitalization, at a distance from the acute stress (Table 4, d8). The discussion of the cessation of treatment between the pharmacist and the medical team could take place during the senior medical visit.

Regarding the communication tools used, both groups mentioned the use of a common tool such as a dedicated part of the discharge letter, already used in the hospital,

<table><caption>TABLE 4 Verbatims for the category 'Planned implementation of deprescribing'.</caption><thead><tr><th colspan="3">Practical implementation of deprescribing</th></tr><tr><th>Themes</th><th>Main sub-themes</th><th>Units of meaning</th></tr></thead><tbody><tr><td>The actors</td><td>The pharmacist is legitimate to do so</td><td>d1 'it needs to be put in the name of the clinical pharmacist who has a quality and legitimacy to do it'</td></tr><tr><td>The format</td><td>This must be done in the form of a proposal</td><td>d2 'I think it must be a submission to the doctors responsible for the medical order'<br>d3 'a recommendation or proposal and that it be discussed with the medical team'</td></tr><tr><td>The tools</td><td>Excessive protocolization is not necessarily a good thing, as it takes away the responsibility of young doctors in particular<br>Develop effective communication tools with the patient and with general practitioners</td><td>d4 'Residents don't feel responsible anymore because of the protocol'<br>d5 'yes it does multiply the thing I think, if the guy gets a hospital report, a liaison letter, a note from the pharmacist it does a lot'<br>d6 'because today not all attending physicians have MS health email addresses that are open'</td></tr><tr><td>The temporality</td><td>Start of hospitalization<br>At the end of the hospitalization to let the acute stress episode pass</td><td>d7 'At the beginning of the hospitalization, it can provide an opportunity to show the patient if he is being monitored that it is going much better without'<br>d8 'wait until she is out of the stressful period and suggest stopping'</td></tr><tr><td>The financial means</td><td>Deimbursement<br>Pay prescribers to stop prescribing</td><td>d9 'The other way to not prescribe drugs is to de-reimburse them'<br>d10 'we could be paid to stop prescribing'</td></tr></tbody></table>

Notes: Group 2, physicians practising in departments with an existing clinical pharmacy activity. Group 1, physicians practising in departments without a clinical pharmacy team.
co-signed by the pharmacist and sent to the GP and the patient. GPs would be reluctant to use emails that they might not receive or read. The vast majority of respondents felt that the creation of a deprescribing protocol was inappropriate. This evoked for them the excessive protocolization and the disempowerment that it entailed for young physicians (Table 4, d4).

At the end of the interview and in both groups, the respondents suggested adopting financial measures such as stopping reimbursement for PPIs, for example, or getting remunerated for deprescribing (Table 4, d10).

## 3.5 | The patient and personalized medicine or the shared medical decision

Physicians emphasized the central role that patients should play in the deprescribing of their treatment. Their understanding was described as a factor of acceptance, and their information was necessary to obtain their agreement. The reasons for discontinuing treatment had to be explained to them so that they would not lose confidence in his GP (Table 5, e1 and e2).

In addition, the respondents expressed weariness with a medicine that was becoming more and more collective and less and less individual. Indeed, it was essential that the patient be placed at the heart of care and that real life take precedence over theory (Table 5, e3 and e5).

## 4 | DISCUSSION

This study shows that hospital doctors are concerned about deprescribing. They emphasize the value of a clinical pharmacist's expertise in the proper use of medicines and have full confidence in the management of discontinuation of treatment, provided this is done in conjunction with the GP and the patient. The conclusions of this study are general on deprescribing, beyond PPIs.

Thematic analysis of the verbatims showed several elements influencing physician/pharmacist collaboration in deprescribing. First of all, deprescribing in a community or hospital setting is not done for many reasons, more practical than ideological: Doctors express a lack of time and sufficient knowledge about the process and are reluctant to stop the treatment started by a colleague. A qualitative study conducted in the United Kingdom by Sawan et al in 2020 showed that the strongest constraint to deprescribing was the lack of time on the part of doctors.²⁹ However, doctors were aware of the need to deprescribe because of the proven toxicity of certain treatments such as PPIs, particularly in the most at-risk populations such as elderly people with multiple drug dependencies. This result may echo another study, which showed that prescribers preferred inertia, defined as the inability to act despite the realization that deprescribing is necessary. Indeed, inaction was preferred to action.³⁰ The issue of deprescribing treatments initiated by other physicians shown in our results is similar to that of other studies

<table><caption>TABLE 5 Verbatims for the category ‘The patient and personalized medicine’.</caption><thead><tr><th colspan="3">The patient and personalized medicine</th></tr><tr><th>Themes</th><th>Main sub-themes</th><th>Units of meaning</th></tr></thead><tbody><tr><td>The patient must be at the centre of PPI deprescribing</td><td>The patient must understand and agree to stop. His understanding is a factor of acceptance<br/>Patients should not lose confidence in their GP</td><td>e1 'The patient needs to understand why the prescription was cut'<br/>e2 'adherence to therapy for chronically ill patients is dependent on the credibility that a patient has and the trust that he or she places in you [...] We have done some work in the hospital, but it is so poorly transmitted to the treating physicians and to the patients that it is rather an abysmal failure'</td></tr><tr><td>The history of each patient must be considered and not everything must be collectivized</td><td>It is not necessarily necessary to protocolize everything<br/>Difference between theory and 'real life'</td><td>e3 'But I think that an algorithmic medicine is very good. But you have to be careful because no one fits into the boxes'<br/>e4 'There is a time when the protocol for everything is useless'<br/>e5 'There are theoretical MA indications and even after real life, real life. [...] Real life, it takes precedence'</td></tr></tbody></table>

Notes: Group 2, physicians practising in departments with an existing clinical pharmacy activity. Group 1, physicians practising in departments without a clinical pharmacy team.
that have found that physicians conveyed their hesitation to intervene with medications that had been prescribed earlier by a colleague or a medical specialist.31,32 Finally, insufficient knowledge in the deprescribing process represents a significant barrier for deprescribing, given that discontinuation is not systematically mentioned, nor presented as a legitimate option, in guidelines issued by professional associations or public authorities, and no criteria for discontinuation are provided in these guidelines, as assessed by Nixon et al.33

More specific barriers were highlighted regarding deprescribing in hospitals. Physicians felt that it was not their role to deprescribe a treatment initiated by a colleague, especially a GP. This practice also challenged the original role of the hospital, which was to provide acute care to a patient. Despite this, physicians recognized that opportunities existed to deprescribe in the hospital setting. The presence of pharmacists and the medication review that they perform during medication reconciliation can facilitate deprescribing in discussion with the medical team. These elements are also described in another study in which they concluded that hospitalization was the best time to reassess a patient's treatment because of access to a multidisciplinary team (physicians and pharmacists) and the patient's availability over a long period of time.29 The pharmacist then appears as an initiator of reflection on deprescribing.

The respondents wanted the deprescribing to be proposed by the pharmacist and discussed with the physicians. This method echoes the results of Whitman et al who proposed to include the pharmacist in a geriatric service to deprescribe unnecessary treatments in elderly cancer patients. He showed that pharmacists, if integrated into the clinical setting, have the potential to play an important role in reducing physician workload.34 However, the decision must be shared between the pharmacist, the hospital physician and the GP who was considered to be the person who knows the patient and their treatment best. This collaboration is also described in numerous studies.29,34 For example, some authors proposed that an alternative approach is for pharmacists to take on the role of prescribing in conjunction with the primary care physician.29 Collaboration between GPs and pharmacists could be promoted, for example, through funding 'refusal to fill' or the provision of evidence-based pharmaceutical opinions. Evidence shows that pharmaceutical opinions and patient engagement can reduce the use of PIMs by 43% within 6 months.35 That is why some changing in pharmacists' scope of practice and funding to support pharmaceutical opinions and facilitate collaboration between community pharmacists and primary care physicians is being developed in some regions.36 Regarding PPI, Bundeff et al demonstrated the significant

impact that clinical pharmacists can have in reducing chronic PPI use within a medical team in an ambulatory care setting when sending recommendations for PPI reduction to the GP the day before each appointment with the treating physician.37

Finally, to successfully achieve deprescribing, physicians emphasized the need to involve the patient. This tripartite (pharmacist/physician/patient) approach to deprescribing is supported by a recent systematic review on barriers to deprescribing, which suggests that an individual's decision to discontinue a drug is influenced by many elements (understanding, trust in the physician).38 Thus, it is essential to place the patient at the centre of the deprescribing of one of his treatments within the framework of a shared decision. Another study on the impact of the pharmacist in reducing the use of inappropriate medication in the elderly was conducted.35 In the study population, 43% of patients did not resume their medication after deprescribing compared to 12% in the arm without pharmacist intervention.35 This significant result indicates that efforts to involve the patient in the deprescribing decision process are more effective than simple communication between the physician and pharmacist.

Our study has limitations. Firstly, the two groups of respondents were not comparable in terms of their practice specialties. The first group was composed of medical specialties, while the second group was composed of surgical specialties. As surgeons are generally more distant from drug-related issues, one would expect their representation of pharmacist deprescribing to be different. However, our results show that the group of physicians from departments without a clinical pharmacist did not have a different representation of the role of the hospital pharmacist than the other group. In both cases, the image of the pharmacist was positive. Regarding the setting of two separate groups, the initial goal was to ensure that there was not a large divergence in discourse between physicians who already had connections with pharmacists and those who did not. Through data analysis, we found that the discourses and representations of possible collaboration were very similar, which allowed us to group the discourses in the presentation of the results, to focus on how to act indifferently with practitioners, whether or not they had relationships with hospital pharmacists. Thus, a pre-existing contact or work experience has little influence on physician/pharmacist collaboration in deprescribing.

Focus group method has its own limitations, and it is important to consider there is a possibility of bias and manipulation through dominating participants, difficulties in distinguishing between an individual view and a group view, and in generalizing the results too.39 Finally,
the number of participants in each group was limited. Nevertheless, it was shown that whether the number of participants discussing a code is high or low, there is no clear pattern and the saturation seems to be reached at the same point.²¹ Despite our desire to balance the two focus groups, some practitioners were ultimately unable to participate. The purpose of the focus group method is to allow for a facilitated discussion on a topic. Typically, focus groups have between three and 12 participants, but having five and seven participants in our study was not a problem since the discussions lasted more than 60 min in each group, which shows that the exchanges were sustained. We can therefore consider our results reliable.

In conclusion, this study provides a better understanding of the elements that influence pharmacist/physician collaboration in deprescribing in a hospital setting. Faced with medical but also economic issues, it makes it easier to envisage a deprescribing process that also involves the patient in a global approach. More specifically, it makes it possible to develop effective strategies to deprescribe PPIs and limit their excessive and unjustified use.

## ACKNOWLEDGEMENTS

The authors would like to thank every physician who participated in the group interviews.

## CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

## ORCID

Jean-François Huon https://orcid.org/0000-0002-8738-4419

## REFERENCES

1. Hilmer SN, Gnjidic D. Deprescribing: the emerging evidence for and the practice of the "geriatrician's salute". *Age Ageing*. 2018;47(5):638-640. doi:10.1093/ageing/afy014

2. McBane SE, Dopp AL, Abe A, et al. Collaborative drug therapy management and comprehensive medication management—2015. *Pharmacother J Hum Pharmacol Drug Ther*. 2015;35(4):e39-e50. doi:10.1002/phar.1563

3. Pottegård A, Broe A, Hallas J, de Muckadell OBS, Lassen AT, Lødrup AB. Use of proton-pump inhibitors among adults: a Danish nationwide drug utilization study. *Therap Adv Gastroenterol*. 2016;9(5):671-678. doi:10.1177/1756283X16650156

4. Othman F, Card TR, Crooks CJ. Proton pump inhibitor prescribing patterns in the UK: a primary care database study. *Pharmacoepidemiol Drug Saf*. 2016;25(9):1079-1087. doi:10.1002/pds.4043

5. Hollingworth S, Duncan EL, Martin JH. Marked increase in proton pump inhibitors use in Australia. *Pharmacoepidemiol Drug Saf*. 2010;19(10):1019-1024. doi:10.1002/pds.1969

6. Lassalle M, Le Tri T, Bardou M, et al. Use of proton pump inhibitors in adults in France: a nationwide drug utilization

study. *Eur J Clin Pharmacol*. 2020;76(3):449-457. doi:10.1007/s00228-019-02810-1

7. Strampelli A, Cerreta F, Vučić K. Medication use among older people in Europe: implications for regulatory assessment and co-prescription of new medicines. *Br J Clin Pharmacol*. 2020; 86(10):1912-1920. doi:10.1111/bcp.14462

8. Vaezi MF, Yang YX, Howden CW. Complications of proton pump inhibitor therapy. *Gastroenterology*. 2017;153(1):35-48. doi:10.1053/j.gastro.2017.04.047

9. Savarino V, Marabotto E, Zentilin P, et al. Proton pump inhibitors: use and misuse in the clinical setting. *Expert Rev Clin Pharmacol*. 2018;11(11):1123-1134. doi:10.1080/17512433.2018.1531703

10. Savarino V, Dulbecco P, de Bortoli N, Ottonello A, Savarino E. The appropriate use of proton pump inhibitors (PPIs): need for a reappraisal. *Eur J Intern Med*. 2017;37:19-24. doi:10.1016/j.ejim.2016.10.007

11. Voukelatou P, Vrettos I, Emmanouilidou G, et al. Predictors of inappropriate proton pump inhibitors use in elderly patients. *Curr Gerontol Geriatr Res*. 2019;2019:1, 7591045-5. doi:10.1155/2019/7591045

12. Boghossian TA, Rashid FJ, Thompson W, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. *Cochrane Database Syst Rev*. 2017;3:CD011969. doi:10.1002/14651858.CD011969.pub2

13. Raghunath AS, Hungin APS, Cornford CS, Featherstone V. Use of proton pump inhibitors: an exploration of the attitudes, knowledge and perceptions of general practitioners. *Digestion*. 2005;72(4):212-218. doi:10.1159/000089727

14. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. *Can Fam Physician Med Fam Can*. 2017;63(5):354-364.

15. Martin P, Tamblyn R, Ahmed S, Benedetti A, Tannenbaum C. A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): study protocol for a cluster randomized controlled trial. *Trials*. 2015;16(1):266. doi:10.1186/s13063-015-0791-1

16. World Health Organization. Framework for Action on Interprofessional Education & Collaborative [Internet]. 2010. Accessed July 14, 2021. http://www.who.int/hrh/nursing_midwifery/en/

17. Santschi V, Rodondi N, Bugnon O, Burnier M. Impact of electronic monitoring of drug adherence on blood pressure control in primary care: a cluster 12-month randomised controlled study. *Eur J Intern Med*. 2008;19(6):427-434. doi:10.1016/j.ejim.2007.12.007

18. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. *Int J Qual Health Care Int Soc Qual Health Care*. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042

19. Tveden-Nyborg P, Bergmann TK, Jessen N, Simonsen U, Lykkesfeldt J. BCPT policy for experimental and clinical studies. *Basic Clin Pharmacol Toxicol*. 2021;128(1):4-8. doi:10.1111/bcpt.13492

20. Guest G, Namey E, McKenna K. How many focus groups are enough? Building an evidence base for nonprobability sample sizes. *Field Methods*. 2017;29(1):3-22. doi:10.1177/1525822X16639015
21. Hennink MM, Kaiser BN, Weber MB. What influences saturation? Estimating sample sizes in focus group research. *Qual Health Res.* 2019;29(10):1483-1496. doi:10.1177/1049732318821692

22. Rabiee F. Focus-group interview and data analysis. *Proc Nutr Soc.* 2004;63(4):655-660. doi:10.1079/PNS2004399

23. Traynor M. Focus group research. *Nurs Stand* (1984). 2015; 29(37):44-48. doi:10.7748/ns.29.37.44.e8822

24. Gundumogula M. Importance of focus groups in qualitative research. *Int J Humanit Soc Stud.* 2020;8(11). doi:10.24940/teijhss/2020/v8/i11/HS2011-082

25. Gould D. Using vignettes to collect data for nursing research studies: how valid are the findings? *J Clin Nurs.* 1996;5(4):207-212. doi:10.1111/j.1365-2702.1996.tb00253.x

26. Norwich B. The role of vignettes in the research of emotional and behaviour difficulties. *Emot Behav Diffic.* 2001;6(1):50-62. doi:10.1080/13632750100507655

27. Braun V, Clarke V. Using thematic analysis in psychology. *Qual Res Psychol.* 2006;3(2):77-101. doi:10.1191/1478088706qp0630a

28. Corden A, Sainsbury R. Exploring ‘quality’: research Participants’ perspectives on verbatim quotations. *Int J Soc Res Methodol.* 2006;9(2):97-110. doi:10.1080/13645570600595264

29. Sawan M, Reeve E, Turner J, et al. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. *Expert Rev Clin Pharmacol.* 2020;13(3):233-245. doi:10.1080/17512433.2020.1730812

30. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. *BMJ Open.* 2014;4(12):e006544. doi:10.1136/bmjopen-2014-006544

31. Palagyi A, Keay L, Harper J, Potter J, Lindley RI. Barricades and brickwalls – a qualitative study exploring perceptions of medication use and deprescribing in long-term care. *BMC Geriatr.* 2016;16(1):15. doi:10.1186/s12877-016-0181-x

32. Spinewine A, Swine C, Dhillon S, et al. Appropriateness of use of medicines in elderly inpatients: qualitative study. *BMJ. 2005;331(7522):935. doi:10.1136/bmj.38551.410012.06*

33. Nixon MS, Vendelø MT. General practitioners' decisions about discontinuation of medication: an explorative study. *J Health

*Organ Manag.* 2016;30(4):565-580. doi:10.1108/JHOM-01-2015-0011

34. Whitman A, DeGregory K, Morris A, Mohile S, Ramsdale E. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. *Support Care Cancer.* 2018;26(12):4105-4113. doi: 10.1007/s00520-018-4281-3

35. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults. *Jama.* 2018; 320(18):1889-1898. doi:10.1001/jama.2018.16131

36. SaferMedsNL. Promoting safe and effective medication use for people living in Newfoundland and Labrador. 2018. Accessed March 8, 2023. https://safermedsnl.ca/

37. Bundeff AW, Zaiken K. Impact of clinical pharmacists' recommendations on a proton pump inhibitor taper protocol in an ambulatory care practice. *J Manag Care Pharm.* 2013;19(4): 325-333. doi:10.18553/jmcp.2013.19.4.325

38. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. *Drugs Aging.* 2013;30(10):793-807. doi:10.1007/s40266-013-0106-8

39. Litosseliti L. *Using Focus Groups in Research.* A&C Black; 2003.

## SUPPORTING INFORMATION

Additional supporting information can be found online in the Supporting Information section at the end of this article.

**How to cite this article:** Gendre P, Mayol S, Mocquard J, Huon J-F. Physicians' views on pharmacists' involvement in hospital deprescribing: A qualitative study on proton pump inhibitors. *Basic Clin Pharmacol Toxicol.* 2023; 133(6):718-728. doi:10.1111/bcpt.13878