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Health Services Research & Development

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Increasing impact of evidence synthesis through integration of first-hand experiences of Veterans and clinicians
This project is designed as a narrative companion to the VA Evidence Synthesis Program (ESP) report entitled "Deprescribing for Older Veterans" which reviews the scientific literature around the effectiveness and harms of deprescribing interventions for older adults.
Why Deprescribe?

Over 40 percent of adults aged 65 and older use five or more prescription medications. While medications are generally started over time to address symptoms, manage chronic conditions, and provide preventive health benefits, the resulting problem of polypharmacy is associated with an increased risk of adverse drug events, drug-drug interactions, and medication non-adherence. It is estimated that 50 percent of older adults take one or more potentially inappropriate medications known to pose risk to the elderly.

In response, clinicians and other health care professionals have been engaged in efforts to reduce polypharmacy among older adults. A comprehensive process of medication review and decreasing of dose or discontinuation is referred to as "deprescribing." In addition to potentially unsafe medications and medications without long-term benefits, targets for deprescribing include medications without clear indication, duplicative medications, and medications that adversely affect cognition and function.

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Deprescribing Stories

We present first-hand, lived experiences of deprescribing from the perspectives of VA patients, clinicians, and pharmacists, who are all healthcare stakeholders contributing to the wellbeing of our aging Veterans. All quotes presented in this product are real quotes from Veterans or clinicians.

Project Methods

We conducted a thematic analysis of semi-structured interviews to gain insight into the first-hand experiences of Veterans and clinicians who have engaged in the deprescribing process. We employed a convenience sampling method to identify physicians representing primary care, geriatrics, and mental health. During interviews, we asked these physicians to identify a Veteran patient with whom they have initiated deprescribing, as well as additional staff who may have worked with the patient during the deprescribing process. We interviewed 10 clinicians (including 4 primary care physicians, 2 geriatricians, 2 psychiatrists,1 clinical pharmacist, and 1 licensed practical nurse) and 5 Veterans. A sociologist trained in qualitative methodology interviewed participants. Interview participation was voluntary, and a $30 gift card was provided to Veterans who were interviewed to compensate them for their time. Interviews lasted 30-60 minutes and were audio-recorded and transcribed verbatim.

We developed semi-structured interview guides based on information from three sources: 1) review of existing literature regarding facilitators and barriers of deprescribing, 2) discussions with physicians who agreed to a pilot interview, and 3) a focus group discussion with a Veteran Engagement Group, which is a standing group of Veterans at the VA Health Services Research and Development Service (HSR&D) Center to Improve Veteran Involvement in Care (CIVIC) who provide guidance to researchers to promote Veteran-centered research design.

The stories presented here are based on the qualitative data collected during these interviews, which represent experiences and perspectives of individual Veterans and clinicians. The Advice page elaborates on several themes that emerged during our analysis.

The VA Quality Enhancement Research Initiative (QUERI) and HSR&D provided funding for this quality improvement pilot project through the Evidence Synthesis Program.

Selected References

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.

Researchers used systematic review methodology to synthesize the results of 21 studies exploring the perceived barriers and enablers for deprescribing potentially inappropriate medications in adults. They identified four emergent themes: problem awareness, inertia, self-efficacy with regard to personal ability to alter prescribing, and feasibility of altering prescribing in routine care environments given external constraints. The authors conclude that more work is needed in developing an understanding of the highly interdependent factors that shape prescriber behavior in order to generate and implement truly effective interventions aimed at fostering deprescribing.

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Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. Challenges and enablers of deprescribing: A general practitioner perspective. PLoS One. 2016;11(4):e0151066.

Researchers used data gathered from semi-structured interviews to investigate the perceived challenges and possible enablers to deprescribing in residential care in two cities in New Zealand. They found that uncertainty combined with a lack of specific evidence-based guidelines, social pressures from nurses and specialists, and poor communication between prescribers at different points of patient care are among the major challenges. Enablers of deprescribing included adequate imbursement, improved communication between physicians at key points of care, appropriate deprescribing guidelines, and involvement of pharmacists in multidisciplinary teams.

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Mc Namara KP, Breken BD, Alzubaidi HT, et al. Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia. Age Ageing. 2017;46(2):291-299.

Researchers interviewed 26 Australian healthcare professionals to explore perceived barriers and enablers for healthcare teams in appropriate medication management for community-dwelling patients with multimorbidity and polypharmacy. They found that a lack of structured approaches with regard to patient preferences, conflicting prescriber advice, treatment adherence, and the optimization of a care plan, combined with workload pressures and poorly defined individual care responsibilities, all contributed to respondents' lack of ownership of multimorbidity and polypharmacy management. Potential facilitators included improved culture, implementation of electronic health records, greater engagement of pharmacists, nurses, patients, and families in care provision, the use

of care coordinators, and the assignment of specific medication review responsibilities to specified health care providers.

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Reeve E, Low LF, Hilmer SN. Beliefs and attitudes of older adults and carers about deprescribing of medications: A qualitative focus group study. Br J Gen Pract. 2016;66(649):e552-560.

Researchers in Australia conducted qualitative focus groups to better understand the attitudes of older adults and carers with regard to deprescribing. They found that the willingness of older adults and carers towards deprescribing was influenced by four main themes: the perception of the appropriateness of the medication, fear of medication withdrawal, dislike of taking medications, and the availability of a withdrawal process. The authors also identified a patient's GP as a strong influencer in both patients and carers attitudes towards deprescribing.

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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.

The authors, Australian researchers, utilized systematic review methods to identify and distill 21 articles addressing barriers and enablers that might influence a patient's decision to cease a medication. They found that three main themes – disagreement/agreement with the 'appropriateness' of the cessation, absence/presence of a 'process' for cessation, and negative/positive 'influences' to cease medications – were the primary barriers and enablers for a patient's decision to cease a medication. Fear of cessation and dislike of medications generally also played a significant role in the decision-making process.

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Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017;38:3-11.

Researchers provide a narrative review of the process of deprescribing, which includes a discussion of the identified barriers and enablers, and a general outline of the deprescribing process. The barriers and enablers the authors identify include perceptions based on a lack of information, fear of consequences, and a lack of perceived agency. The authors believe that the deprescribing process is best enabled by a shared decision-making process informed by the best available evidence.

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Helpful Resource
Project Team
Steven K. Dobscha
MD
Vivian Christensen
PhD
Stephanie Tallett
UX Design
VA HSR&D Center to Improve Veteran Involvement in Care VA Evidence Synthesis Program (ESP) Coordinating Center VA Clinical Informatics & Data Management Office (CIDMO)
Portland, OR Portland, OR Portland, OR
steven.dobscha@va.gov vivian.christensen@va.gov stephanie.tallett@va.gov
Khaya Clark
PhD
Emma Kenyon
Research
VA HSR&D Center to Improve Veteran Involvement in Care VA HSR&D Center to Improve Veteran Involvement in Care
Portland, OR Portland, OR
khaya.clark@va.gov emma.kenyon@va.gov