Hello deprescribers, welcome to our 8th guest blog post. Today we have Dr. Kristie Weir from the University of Sydney summarizing key findings from her recent Ph.D. dissertation that explored preferences around communication and decision-making in deprescribing.
Optimizing medication decisions includes involving the patient
As deprescribing researchers, we find ways to reduce polypharmacy and inappropriate medication use (well, try to!). Deprescribing is a safe and positive intervention. In deprescribing, we always need to consider the patient’s circumstances, level of functioning, care goals and preferences. If we don’t involve older adults in discussions about their medicines, it is unlikely that their medication regimen can be optimized. This is because what is appropriate depends to a large extent on the context, circumstances and -of course- preferences of the older individual.
We know that medication reviews provide a great opportunity to assess the appropriateness of a medication regimen and may include implementing practical tools to support deprescribing. We also know that medication reviews are most appropriate and effective when there is engagement between the patient, the professional conducting the review (i.e. a pharmacist) and the patient’s prescribing doctor(s).
Exploring communication and decision-making around deprescribing
My thesis explored communication and decision-making about medicines and deprescribing from the perspectives of older patients, their companions, pharmacists and GPs. I conducted a series of qualitative and mixed methods studies to shed light on the attitudes and experiences of key players involved in the deprescribing process in clinical practice.
Here is a quick summary of what I found…
1: We need to tailor deprescribing interventions
My thesis revealed substantial differences between older patients, pharmacists and GPs in their experiences with and attitudes towards medicine discussions. It is important to understand the diversity and individuality of older patients, pharmacists and GPs in this context in order to tailor interventions and identify key barriers to medicines optimization.
2: Patients have different decision-making preferences and willingness to deprescribe
The first study in my thesis found that older patients differed in terms of their attitudes towards medicines, decision-making preferences and their willingness to deprescribe. Some had positive attitudes towards medicines, preferred to leave most decisions to their doctor and were resistant to deprescribing (Type 1). Others voiced ambivalent attitudes towards their medicines, preferred a more proactive role in decision-making and were open to deprescribing if their medicines were causing problems or were not beneficial (Type 2). A third group (Type 3) consisted of patients who were mostly frail and perceived they lacked knowledge about their medicines. They preferred to defer decisions about their medicines to others (doctor or their companion).
3: How patient-centred are pharmacist home medication reviews?
My second study (here and here) found that pharmacists varied in their approach to Home Medicines Reviews (HMRs). Some pharmacists had a more patient-centred approach to medication reviews whilst others focused mainly on the practical aspects of medications.
In this study, we developed and tested the feasibility of the Medicines Conversation Guide (the Guide), a flexible tool to support patient involvement in discussions about medicines. We found that pharmacists approached HMRs and older patients’ attitudes towards polypharmacy and deprescribing differently from one another. This influenced how the Guide was used by pharmacists and how it was received by older patients. Participants reported that the Guide supported patient involvement in the HMR and facilitated communication between the patient, pharmacist and GP. The Guide prompted pharmacists to consider the patient at the forefront of the review rather than the referring GP alone. However, some of the Guide questions were difficult for patients to understand (e.g. trade-offs related to quality of life versus length of life) and pharmacists were reluctant to ask some questions due to certain topics considered to be ‘off-limits’ or not appropriate for an HMR discussion (i.e. patients’ fears and worries, goals and preferences).
4: How do GPs incorporate patient goals into medication decisions?
My last study examined attitudes and experiences using HMRs to optimize medicines for their older patients and the extent to which they perceived different elements of HMRs to be of practical value. We found variability in the extent and the way GPs used HMRs. Overall, HMRs were found to be useful for educating patients about their medicines, understanding the patient’s home environment and the pharmacist spending time with the patient to improve their knowledge about medicines. Barriers to the effective use of HMRs included patient resistance to having their medicines reviewed, the complicated HMR process and the generic nature of HMR reports.
We also explored how valuable GPs perceived patients’ goals and preferences to be when making medication decisions. This analysis revealed three practice patterns used by GPs. Some GPs considered goals and preferences a lower priority; some saw goals as central to decision-making, and some considered goals and preferences but would not explicitly elicit information about them.
Key message: We need to tailor deprescribing interventions
My thesis found distinct types of older patients, pharmacists and GPs in relation to deprescribing decision-making. Older patients varied in terms of their attitudes towards medicines, willingness to deprescribe, and decision-making preferences. Pharmacists varied in their approach to HMRs, their communication style and their perceived role in communicating with patients about their goals and preferences. Finally, GPs varied in how important they considered patients’ goals and preferences to be, how they prioritized medicines, their approach to deprescribing, and how they utilized HMRs. Becoming familiar with the differences in these three key players could facilitate medicine optimization and engaged communication. Tailoring interventions such as decision support tools, goal elicitation strategies and conversation guides to these differences will support shared decision-making about deprescribing.