|Ahead of print publication
A young clinician's perspective on deprescribing in elderly patients: A pilot study
Vivek Aggarwal1, S Shankar1, Suryakant2, Manish Manrai1, Vivek Vasdev3, Anuj Singhal1, AK Yadav4
1 Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
2 O/o DGAFMS, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Geriatrics, Armed Forces Medical College, Pune, Maharashtra, India
4 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||13-Apr-2020|
|Date of Decision||14-Jun-2020|
|Date of Acceptance||04-Feb-2021|
|Date of Web Publication||02-Apr-2021|
Department of Internal Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Young doctors have various barriers and hesitations towards de-prescribing. This study was planned to assess Young Clinician's perspective on deprescribing in elderly population from India. Methodology: Observation cross-sectional study done in a tertiary care hospital of Western Maharashtra. A web link consisting of 12 survey questions was shared on smart phones of postgraduates working in clinical specialties. Attitudes, knowledge, barriers and approach towards deprescribing were assessed. Results: Out of 64 doctors 30 doctors responded and completed the survey. Mean age was 32.6 years. Most common cause for deprescribing was to reduce the adverse drug reactions (76.33%), lack of definite indication (63.33%). Most common drug to be de-prescribed were multivitamins (70.66%), benzodiazepines (46.66%) and antiplatelets (43.33%). The most common barrier for de-prescribing was altering the prescription of another doctor (56.66%), lack of time and concerns on the adverse effect (36.66%). Ninety percent of the doctors were not aware of any deprescribing criteria and 70% did not have any specific approach. Conclusion: Deprescribing of drugs is a very important concept, which needs to be included in training the undergraduate medical students, postgraduate medical students and Pharmacy students.
Keywords: Deprescribing, elderly, potentially inappropriate medicines
| Introduction|| |
Deprescribing is a process of stopping, tapering, or discontinuing a drug with a goal to reduce polypharmacy and improve the clinical outcomes. According to a recent editorial by the American College of Family physicians, deprescribing is absolutely necessary for good prescribing. With a rapid rise in geriatric population around the globe, there is an exponential increase in multi-morbidity, polypharmacy, and prescribing of potentially inappropriate medicines (PIMs) which makes deprescribing very important intervention in daily practice. Moreover, geriatric population is complex, more vulnerable and heterogeneous which makes them more vulnerable to adverse drug reactions, drug-drug and drug-disease interaction., Deprescribing is a major challenge faced by doctors in today's era due to ever increasing number of diseases, drugs, changing guidelines, and indications. A study from Singapore emphasizes common barriers and lack of approach of medical practitioners toward deprescribing. Fear of adverse drug reactions, shortage of time, inability to convince patient and their relatives, and insufficient knowledge were the main barriers in deprescribing.,, Deprescribing has shown to have significant mortality benefit along with reduction in health-care cost within available resources.,,, A study done on Indian doctors by Kamath showed poor awareness about deprescribing. This study was planned to assess the clinician's perspective on deprescribing in elderly population from India. The objective was to assess perceptions and attitudes about de-prescribing in elderly, common medication deemed “de-prescribable,” determinants affecting prescribing behavior, barriers faced in deprescribing and to assess awareness about potential inappropriate medications and deprescribing criteria.
| Materials and Methods|| |
It was an observation cross sectional study done on all the willing young doctors working in a tertiary care hospital of Western Maharashtra. All the young doctors undergoing post graduate training in clinical specialties were send a web link for online survey on deprescribing on their smart phones. The survey consisted of total 12 questions. Questions were framed to assess their years of experience, three most common drugs deprescribed, frequency, and common reasons for deprescribing. Survey also analyzed their views, attitudes, knowledge, barriers, and approach toward deprescribing [Table 1]. This questionnaire was prevalidated by three independent physicians and was pilot tested on 5 resident doctors of final year. The study was approved by institutional ethical committee.
All these questions were then formatted and included in an online form. The web link of the online form was shared to all the residents and doctors on their smart phone. The response received was automatically collated and saved.
Data were collated and analyzed to assess the attitude, knowledge, and practices on deprescribing. Most commonly deprescribable drugs, common barriers to deprescribing, and approach to deprescribing were also assessed. After the survey was complete, web links on appropriate and rationale prescribing and identification of PIMs were send to the participating doctors to enable them to improve prescribing practice and to be able to deprescribe more confidently (American Geriatric Society BEERS criteria to identify PIM and STOPP/START criteria to stop and start medicines). The data were collated and analyzed in IBM Statistics SPSS software Version 22.0 (IBM Corp, Armonk, NY, USA) using descriptive statistics.
| Results|| |
Total 64 doctors were approached through social media on their smart phones to participate in the survey. Out of 64 doctors 30 doctors responded and completed the online survey. The data were collated and analyzed in IBM Statistics SPSS software Version 22.0 (IBM Corp, Armonk, NY, USA) using descriptive statistics. Mean age of doctors were 32.6 years with male to female ratio of M:F = 5:1 (25/05). Thirty percent (9/30) of doctors had a clinical experience of more than 10 years where as 70% had clinical experience of <10 years. Eighty percent of doctors (24/30) were junior residents, 20% (6/30) were senior residents. Sixty percent (18/30) of young doctors agreed that they deprescribed drugs occasionally only where as 20% agreed of deprescribing drugs at least few times a week.
The most common cause for deprescribing the medicine was to reduce the adverse drug effects to the patient in 76.33% (24/30) followed by lack of definite indication of a drug in 63.33% (19/30) and minimal benefit of the medicine in 50% (15/30) patients. The most common drug to be deprescribed was multivitamins in 70.66% (23/30) followed by benzodiazepines in 46.66% (14/30) and antiplatelets in 43.33% (13/30) [Table 2]. Fifty percent of doctors agreed that they did not have adequate knowledge about deprescribing medicines, and 43.33% felt that deprescribing can do more harm than benefit.
The most common barrier for deprescribing was altering the prescription of another doctor as rationale of starting such a drug was not very clear as seen in 56.66% (17/30). The second most common barrier to deprescribing was lack of time and concerns on the adverse effect after stopping the drug as seen in 36.66% [Table 3].
Eighty percent (24/30) of doctors felt that regular lectures on deprescribing specific medications will enable them to deprescribe the medicines in a better way. Around 70% (21/30) felt that strong departmental focus on deprescribing and providing of specific guidelines on will enable them to deprescribe rationally. Role of flagging PIMs by a pharmacist was felt in 30% whereas 10% wanted a clinical pharmacologist in their team.
Ninety percent of the doctors were not aware of any criteria to identify the PIMs in the elderly and 70% did not have any specific approach toward deprescribing. Seventy percent of doctors did not have any specific approach toward deprescribing whereas remaining 30% were following some prescribing tool like STARRT/STOPP criteria or medicine appropriateness index.
| Discussion|| |
Deprescribing becomes important in today's health scenario as patient visit multiple doctors for various ailments leading to increase number of drugs which causes increase in number of PIMs with increase adverse drug reactions., Moreover, there are number of physiological changes due to aging which effects the pharmacokinetics and pharmacodynamics of different drugs necessitating either stop/avoid a particular drug or to start in a minimum possible dose. In a study from Singapore, almost two-third of doctors felt that deprescribing will be beneficial to their patients but three forth of them were not aware of any specific framework or approach toward deprescribing. In our study also 70% of the young doctors did not have any specific approach toward deprescribing. Thus rationalizing of the prescription and stoppage of all unnecessary and PIMs is very important in our geriatric population especially with multiple morbidities and frailty
It has been seen that in medical practice, doctors are trained to prescribe medicines and prescribing is considered as social obligation, whereas deprescribing is considered as going against the tide. In a study done in junior doctors, it was seen that most of them were not comfortable in doing medicine review and altering the medicines without consulting seniors and change in our educational approach was suggested. Similar study done on undergraduate medical and pharmacy students in London revealed that the term “deprescribing” was not very familiar to the students In our study also, we noted that 40% of junior doctors agreed that they do not have any specific approach toward deprescribing and 90% were not aware of any criteria to review the prescription and identify PIMs. Thus, it is very important to introduce the concept of “deprescrbinig” at undergraduate and post graduate level to train and sensitize them to identify inappropriate and unnecessary medicines which can be considered to be deprescribed can be reviewed and if possible stopped. Training modules especially in the form the development of objective structured clinical examination models, pharmacovigilance, medication review in acute care and using digital prescriptions can go a long way in identifying the potentially deprescribable drug. However, deprescribing needs to be clinically supervised and it is very important to develop a systematic framework, approach, and identify potential gaps to enable our doctors to deprescribe rationally.,
In our study, the most common barrier in deprescribing was hesitancy in stopping the medicine prescribed by another doctor followed by adverse drug reactions, lack of time, and insufficient knowledge on de-prescribing. Similar findings were noted in a study from Singapore where common barriers to deprescribing were medicine prescribed by another doctor, lack of time, and insufficient knowledge. Another recent study showed that junior doctors were not comfortable in deprescribing the medicines as 80% wanted to consult their seniors or the prescribing doctor before stopping a drug and almost 90% felt that changing or stopping of medicine should only be done by a senior doctor or consultant. Around 80% were not aware about any medicine review tool. In a study done by Goyal et al. the most common reason for deprescribing was a known adverse reaction to a drug or a fear of adverse drug reaction.
The most common drug to be deprescribed in our study was multivitamins followed by benzodiazepines and antiplatelets. Proton pump inhibitors (PPIs) were deprescribed only in 35 of the patients. In a study done the commonly deprescribed drugs were laxatives, NSAIDs, multivitamins, PPIs, and antithrombotics. In our studies, very less young doctors were stopping PPIs which may be due to poor awareness in young doctors and increased resistance from the patients.
The involvement of patient and their relatives is very important in considering deprescribing. In our study, it was seen that resistance from patient and relatives was an important challenge faced by young doctors in deprescribing. Similar findings were noted in a study done by Scott et al. showed substantial amount of resistance from patients and their caregivers to stop or modify treatment. However, in a study from the United States, majority of the elderly patients were receptive to stop their medicines on advice of their family/treating physician. In a recent systematic review done on elderly more than 65 years with limited life expectancy, involvement of relative, self-assurance skills of health provider, counseling as a team, and strong departmental and organizational commitment were important factors in convincing the patient and their relatives on deprescribing.
Fragmented medical care and conservative approach are the main barriers in deprescribing. In the above study, it was also noted that the involvement of patient and shared decision making along with coordination of care plays a very important role in deprescribing. Thus, a concept of a primary care physician for elderly is very important who remains one point of contact between patients and other supespcialities and can coordinate the overall care. This will go long way in reducing polypharmacy, improve patient compliance, and outcomes and proper management of available resources.
Deprescribing is an effective way of rationalizing drug therapy in elderly and has become a very important of good prescribing practice in recent times., Thus, deprescribing is a very important practice to reduce the adverse drug-related events, improving outcomes, and reducing health-related cost in elderly especially in patients visiting multiple doctors. A survey done in general practitioners from Switzerland suggested that there was a need of developing a tool which may help them to balance risks and benefits of the prescribed medicines, especially in frail elderly, and may be useful in deprescribing. Pharmacist can play a very important role in deprescribing as seen in a study done by Ali Ellibedeni where for inpatients in the hospital with multiple comorbidities pharmacist intervened actively in helping to deprescribe the medicines or reduce the dose. This intervention led to decrease in hospital readmission rate by almost 80%. The stopped drug was reintroduced only in <10% of time. Similar findings were noted in a study done by Cheong ST, where pharmacists actively deprescribed medicines and 75% of the time treating doctor agreed with the pharmacist opinion. In another recent study, 54 geriatricians and pharmacists from the UK got together and described different deprescribing enablers based on evidence-based interventions to develop a hospital deprescribing implementation framework. In our study also, 30% of young doctors felt that pharmacist can play a very important role as an enabler to deprescribe medicines.
The limitation of our study was a small sample size. Second, out of the 64 doctors approached only 30 responded. The reasons for nonresponding were not reported. The responses of responders may be different from nonresponder. The doctors surveyed in this study were practicing in a public care setting with medicines being available free of cost which may have led to a bias in assessing deprescribing behavior.
| Conclusion|| |
Seventy percent of young doctors did not have any specific approach and 90% were not aware of any criteria to be able to deprescribe. Most commonly deprescribed drug was multivitamin, benzodiazepines and antiplatelets. Common barriers to deprescribe in young doctors were altering prescription of another doctor, fear of adverse reaction, and lack of time. Regular lectures, specific guidelines, and strong departmental focus will were seen as main enablers to deprescribe in a better way.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]