title: Exploring different aspects related to making and implementing deprescribing decisions in primary care settings
Creators: name: Vidonscky Lüthold, Renata
Publisher: name: Universität Bern
Year: 2025
Subjects: subject: 360 Social problems &amp; social services
subject: 610 Medicine &amp; health

description: Background
The high rate of inappropriate polypharmacy (use of ≥5 medications [1]), has been considered a public health problem due to its association with adverse outcomes, including increased risk for falls, adverse drug reactions, declined functional ability and cognitive capacity, and worsened nutritional status [2-6]. Regular medication reviews and deprescribing (the process of stopping or reducing medications [7]) should be carried out to minimise the risk of medication-related problems, especially among older patients with polypharmacy. However, making and implementing deprescribing decisions in clinical practice is challenging for different reasons.
One of the most common inappropriate medication types are proton pump inhibitors (PPI). Nevertheless, the rates of potentially inappropriate PPI prescriptions have been increasing [8-10]. Inappropriate prescribing of PPIs has been associated with adverse health events and unnecessary costs [8, 11, 12]. General practitioners (GPs) usually have a long-term relationship with their patients and are informed about their patients’ medications, medical conditions, and preferences. GPs have therefore a crucial role in the optimisation of PPI use and prescribing. To optimise the prescriptions of PPIs in primary care, it is important to understand how GPs manage PPI prescriptions in clinical practice and how these prescriptions evolve over time. Little is known about how effective increasing GPs' awareness of inappropriate PPI prescriptions would be in optimising PPI prescribing. Understanding how GPs manage potentially inappropriate PPI prescriptions among their patients will help the development of interventions to optimise PPI prescriptions in primary care settings.
Furthermore, shared decision-making has a crucial role in deprescribing, and decisions about whether and how to stop or reduce medications should consider patients’ views and preferences [13, 14]. In this context, it is important to understand patients’ attitudes towards deprescribing. There is a lack of evidence on which specific medications patients would be more willing to have deprescribed and why. Understanding patients' attitudes towards deprescribing specific medications will help to design tailored deprescribing interventions in clinical practice that consider patients’ preferences.
Older patients with polypharmacy do not only use prescription medications, but also over-the-counter substances, such as dietary supplements. The use of dietary supplements is widespread in developed countries, such as Switzerland [15-17]. Nevertheless, dietary supplements are often used inappropriately, for instance, when there is no indication for their use [18, 19]. Patients are often unaware of the potential risks of supplement use, and therefore often they do not disclose this use to their GPs [20, 21]. However, for a successful implementation of medication reviews and deprescribing, GPs should be aware of all the medications used, including dietary supplements. There is still a lack of evidence focusing on GPs’ and patients’ attitudes towards deprescribing dietary supplements.
Finally, the involvement of pharmacists and their collaboration with GPs may facilitate the conduct of medication reviews and enhance the process of withdrawal or reduction of inappropriate medications [22-28]. However, more research is needed to better understand the factors associated with pharmacists’ willingness to make deprescribing recommendations and their preferences for interprofessional collaboration with physicians for optimising medications in the Swiss context.
Aims
Each one of the four projects involved in my PhD targets different aspects related to medication optimisation and deprescribing in primary care settings. The overall aim of this thesis was to investigate patients’ and healthcare professionals’ attitudes towards optimising medication use in primary care settings, including the use of dietary supplements. My PhD research is guided by the following four aims:
Aim 1: To investigate the prevalence of potentially inappropriate PPI prescribing in a sample of patients in Swiss primary care settings and to evaluate how GPs manage patients with potentially inappropriate PPI prescribing after being aware of this potentially inappropriate prescribing among their patients.
Aim 2: To explore patients’ attitudes towards deprescribing specific medications in 14 countries, by investigating which medications patients were most willing to have deprescribed, the reasons why, and patient factors associated with their willingness to deprescribe.
Aim 3: To investigate the attitudes of patients with polypharmacy towards dietary supplement use, and to explore patients’ and their GPs’ willingness to reduce or stop the intake of these supplements.
Aim 4: To explore pharmacists' perspectives on medication review and deprescribing, as well as their preferences for interprofessional collaboration regarding medication optimisation within Swiss primary care settings.
Methods
For Aim 1, we recruited 11 GPs working in the canton of Bern in Switzerland, who participated in a specific quality circle (“quality circles” are meetings in which a small group of GPs reflect together to improve their care practice [29]). This quality circle meeting had the aim to raise the GPs’ awareness of optimising PPI prescriptions by instructing GPs to flag patients as having a potentially inappropriate PPI prescription in their medical records. We used a convenience retrospective sampling strategy, in which GPs were asked to use their electronic medical records to screen all patients they had seen before the baseline (June 1st, 2021) until they find the first 20 patients who had an active PPI prescription for ≥8 weeks. After identifying these patients, GPs flagged potentially inappropriate PPI prescribing in their medical records. After 12 months, we asked the same GPs whether the potentially inappropriate PPI prescriptions of those flagged patients had changed and, if so, how. We used multilevel logistic regression adjusted for the clustering effect at the GP level to analyse the association between patient and GP characteristics and the frequency of deprescribing.
Aim 2 and Aim 3 are part of the same cross-sectional study. For Aim 2, national coordinators from 14 countries recruited 10 GPs each, and each GP recruited 10 patients (≥65 years old with ≥5 regular medications). Patients then completed an anonymous survey about their attitudes towards deprescribing. We described patient attitudes towards deprescribing, as well as the number and types of medications patients reported that they would like to stop or reduce. We used multilevel logistic regression analysis adjusted for the clustering effect at the country level to investigate the association between patient characteristics and wanting to stop or reduce medications.
For Aim 3, we used the same recruitment strategy, but it involved additional questionnaires only for Switzerland. For Aim 3, older patients with polypharmacy and their GPs were invited to respond to a survey on patients’ use of dietary supplements and attitudes towards deprescribing those. We described and compared their responses regarding dietary supplement use and willingness to deprescribe those, and assessed the association of supplement disclosure with patients' characteristics using multilevel logistic regression analysis.
For Aim 4, a random sample of 1000 pharmacist members of the Swiss pharmacists association pharmaSuisse was invited to respond to an online survey on medication review, deprescribing, and interprofessional collaboration for medication optimisation. The survey had three case vignettes of multimorbid patients aged ≥80 years old with potentially inappropriate polypharmacy, and with different levels of dependency in activities in daily living (ADL) and history of cardiovascular disease (CVD). Pharmacists responded if and which medications they would deprescribe in each case vignette. We calculated the proportions of pharmacists’ willingness to deprescribe by case vignette and performed a multilevel logistic regression analysis to assess associations between pharmacist characteristics, patient history of CVD and dependency in ADL, and willingness to deprescribe.
Results
For Aim 1, we found that potentially inappropriate PPI prescribing was common in Swiss primary care settings, with 41% (n=85) out of the 206 patients with a PPI prescription having a potentially inappropriate PPI prescription. After raising GPS’ awareness of such potentially inappropriate prescriptions, deprescribing was possible for 35% (n=29) of the patients having a potentially inappropriate PPI prescription. The most frequently mentioned reasons for deprescribing not being possible were a lack of discussion with the patient (no contact or no time), the presence of symptoms requiring the PPI, or the unwillingness of the patient to deprescribe. Aim 1 resulted in the Article 1 of this thesis.
For Aim 2, we recruited 1,340 patients (average 96/country), of which 82% (n=1,089) reported being satisfied with their medications. 81% (n=1,088) of the patients were willing to deprescribe if their doctor said it was possible and 44% (n=589) said they would be willing to have at least one of their medications deprescribed. The three most commonly reported medication types for deprescribing were diuretics (n=111, 11%), lipid modifying agents (n=109, 11%), and agents acting on the renin–angiotensin system (n=83, 8%). The odds of being willing to deprescribe specific medications were higher for patients with less satisfaction with medications (OR=0.31, 95%CI 0.21 to 0.47) and lower trust in their GP (OR=0.96, 95%CI 0.93 to 1.00). Aim 2 resulted in Article 2.1 of this thesis.
For Aim 3, we collected data from 10 GPs (3 (30%) female, average age 52 years (SD=8)) and 65 of their patients (29 (45%) female, average 7 patients per GP). We found that 70% of the patients were taking ≥1 supplement (n=45). On average patients reported to be using 3 supplements (SD=2). For 60% (n=39) of the patients, GPs were unaware of ≥1 supplement used. 8% (n=5) of patients and 60% (n=6) of GPs reported ≥1 supplement they would be willing to stop or reduce, and none of the supplements reported by GPs and patients to deprescribe matched. Aim 3 resulted in Article 3 of this thesis.
For Aim 4, we collected data from 138 pharmacists: 113 (82%) were female, their mean age was 44 years (SD=11), 66% (n=77) reported having never received any specific training on how to conduct structured medication reviews, 83 (72%) reported to be confident in identifying deprescribing opportunities, and 88 (81%) wished to be more involved in the process of medication review and deprescribing. All pharmacists were willing to deprescribe ≥1 medication in all vignettes. Patients with CVD were at lower odds of having medications deprescribed (OR=0.27, 95%CI 0.21 to 0.36). Willingness to deprescribe was lower with higher dependency in ADL (medium versus low dependency: OR=0.68, 95%CI 0.54 to 0.87, high versus low dependency: OR=0.72, 95%CI 0.56 to 0.91). However, the joint presence of medium/high dependency in activities of daily living and a history of CVD increased the odds of making a deprescribing suggestion (CVD x medium dependency: OR=1.61 95%CI 1.11 to 2.33, CVD x high dependency: OR= 1.75 95%CI 1.21 to 2.52). In sensitivity analysis, higher levels of dependency in ADL had lower odds of willingness to recommend deprescribing only in cases without history of CVD (medium versus low dependency: OR=0.69, 95%CI 0.54 to 0.87, high versus low dependency: OR=0.72, 95%CI 0.57 to 0.91), but it was different in cases with history of CVD (medium versus low dependency: OR=1.10, 95%CI 0.83 to 1.47, high versus low dependency: OR=1.26, 95%CI 0.95 to 1.67). The odds of recommending deprescribing were also higher for pharmacists who had received training in medication review (OR=2.48, 95%CI 1.38 to 4.44). Aim 4 resulted in Article 4 of this thesis.
Conclusions
This thesis sheds light on different aspects related to patients’ and healthcare professionals’ attitudes towards medication optimisation and deprescribing. First, the finding that raising GPs’ awareness of potentially inappropriate PPI prescribing resulted in deprescribing potentially inappropriate PPIs in only 35% of the patients suggests that more personalised and targeted interventions are necessary to successfully implement deprescribing of potentially inappropriate PPIs. Second, our findings show that patients’ willingness to have medications deprescribed is lower when patients are asked about specific medications compared to the literature asking non-specific questions. This could be one of the reasons why willingness to deprescribe has not yet been found to translate to real-world medication changes and highlights the need for measures that reflect more accurately the patients’ deprescribing attitudes in real-life clinical situations. A better understanding of which types of medications patients are more willing to have deprescribed can inform the scope of future deprescribing interventions that consider patients’ preferences. Third, Swiss GPs were unaware of many dietary supplements used by their older patients with polypharmacy, which may affect medication optimisation efforts. Older adults with polypharmacy seemed to be unsure about the benefits, necessity, and possible risks of dietary supplements and were not willing to have those deprescribed. This highlights the need to involve and educate patients in these regards. Fourth, Swiss pharmacists were willing to make deprescribing suggestions for older patients with polypharmacy, but most reported having received no specific training on how to perform structured medication reviews. Pharmacists would like to be more involved in the process of medication review and deprescribing, which should be leveraged in the context of Swiss primary care settings. Our findings help to better understand patients’, GPs’, and pharmacists’ attitudes towards deprescribing. This in turn will inform future interventions that aim to successfully implement deprescribing and medication optimisation in primary care settings.