MANAGERIAL

Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences

Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH

veruse of can lead to an array of unintended consequences, including adverse drug events, drug–drug ABSTRACT O interactions, financial hardship, and decreased patient satisfaction.1-3 —often defined as 5 or more medica- OBJECTIVES: could reduce the risk of harm tions—is estimated to affect more than 1 in 3 adults older than 65 from inappropriate . We characterized patients’ acceptance of deprescribing recommendations from years, and up to 79% of older adults may be prescribed a potentially pharmacists, primary care providers (PCPs), and specialists inappropriate medication.4,5 One approach to reducing these harms relative to the original prescriber’s professional background. is deprescribing, defined as the proactive, intentional discontinu- STUDY DESIGN: Secondary analysis of national Patient ation of a medication that either no longer provides the expected Perceptions of Discontinuation survey responses from outcomes or has potential harms that outweigh potential benefits.6,7 Veterans Affairs (VA) primary care patients with 5 or Deprescribing should be considered part of the good prescribing more prescriptions. continuum, incorporating patient preferences and goals of care METHODS: We created 4 relative deprescribing authority into that decision-making process.8 Nevertheless, the best way to (RDA) outcome groups from responses to 2 yes/no (Y/N) items: (1) “Imagine…a specialist…prescribed a medicine. integrate deprescribing into routine clinical care remains unclear. Would you be comfortable if your PCP told you to stop...it?” A barrier to effective deprescribing occurs when patients and (2) “Imagine…your VA PCP prescribed a medicine. Would receive care from multiple clinical providers,9 especially across you be comfortable if a VA clinical pharmacist [Pharm] told you to stop…it?” Multinomial regression associated patient multiple healthcare systems. Such fragmentation of care can factors with RDA. create uncertainties as to which clinician is responsible for managing a particular medication. When multiple providers care RESULTS: Respondents (n = 803; adjusted response rate, 52%) were predominantly men (85%) and older than for 1 patient, some clinicians may be reluctant to make decisions 65 years (60%). A total of 281 (38%) respondents said no to about a treatment plan initiated by another.10 This reluctance both questions (PCP-N/Pharm-N) and 146 (20%) said yes may result from feeling that the clinical problem is beyond their to both (PCP-Y/Pharm-Y). A total of 155 (21%) said no to a PCP stopping a specialist’s medicine but yes to a pharmacist scope of practice, uncertainty about the original prescriber’s stopping a PCP’s (PCP-N/Pharm-Y). A total of 153 (21%) intentions, or hesitance to interfere with another professional’s said that a PCP could stop a specialist’s medication but a opinion.11 The difficulties of delineating clear roles for primary pharmacist could not stop a PCP’s (PCP-Y/Pharm-N). In adjusted models (reference, PCP-N/Pharm-N), those with care providers (PCPs) and specialists have persisted for decades.12 greater medication concerns were more likely to respond Some have attempted to define a hierarchy of care from simpler PCP-Y/Pharm-Y (odds ratio [OR], 1.45; 95% CI, 1.09-1.92). to more complicated problems, describing roles for nurses, PCPs, Those with more interest in shared decision making were and specialists.13 Parsing clinical responsibilities, including the more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04-1.92). Those with greater trust in their PCP were less ability to deprescribe, has become even more complicated as the likely to respond PCP-N/Pharm-Y (OR, 0.52; 95% CI, 0.34-0.81) professional jurisdiction and autonomy of nurse practitioners, but more likely to respond PCP-Y/Pharm-N (OR, 2.16; 95% CI, physician assistants, and clinical pharmacists have expanded.14-16 1.31-3.56) or PCP-Y/Pharm-Y (OR, 1.83; 95% CI, 1.13-2.98). Deprescribing is not only a provider behavior but also requires CONCLUSIONS: Understanding patient preferences of that the patient follow the recommendation. Patients may accept RDA can facilitate effective design and implementation of deprescribing interventions. and follow deprescribing recommendations from some providers and not others. Some patients believe that their PCP is responsible for overseeing all care management and is able to change the plans Am J Manag Care. 2019;25(4):192-198

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of specialists; other patients preferentially value TAKEAWAY POINTS the additional training obtained by specialists.17 Patients’ perceptions may also vary based on Patients vary in their attitudes toward which providers have the authority to deprescribe the severity of their medical condition or their medications. relationship with the clinician. It is important ›› In this study, 38% of respondents indicated that they would not want their primary care to ascertain the extent to which patients accept provider (PCP) to discontinue a medication prescribed by a specialist, nor would they want a clinical pharmacist to discontinue a medication prescribed by the PCP. the authority of any individual provider to ›› At the other end of the spectrum, 20% of patients indicated comfort with both their PCP and deprescribe a medication. Given the unknown a pharmacist deprescribing a medication prescribed by a specialist and PCP, respectively. influence of provider type on patient interest ›› Understanding patient preferences for and attitudes toward who can make deprescribing in deprescribing, we sought to characterize recommendations can facilitate effective design and implementation of interventions. patients’ willingness to accept the deprescribing of medicines by different providers as might occur in the context of a hierarchy of professional authority. as well as respondent characteristics (including self-reported health status, medical conditions, and healthcare utilization [eg, METHODS outpatient visits, hospital admissions, and other residential care]). Study Design, Setting, and Population Survey Administration We conducted a national mail survey of veterans receiving Veterans We mailed subjects a letter introducing the survey objectives and Affairs (VA) primary care. We used the VA Corporate Data Warehouse informing them of its upcoming arrival. One week later, we mailed to identify patients with 5 or more concurrent prescriptions for the 12-page survey instrument, a $5 incentive, and an opt-out 90 days in the medical record, at least 1 primary care visit during postcard. Nonrespondents received a reminder letter 2 weeks later, that same time frame, and at least 1 additional visit in the prior and a second survey was sent to remaining nonrespondents after year. We identified 448,155 patients and randomly sampled 1600 2 additional weeks. Subjects who could not be contacted (mail subjects. This sample size was based on (1) guidelines for adequate undeliverable or notification received of their death) were removed sample size required for the primary psychometric analyses18 and from the administration cycle. (2) anticipated response rates. Women constituted 5.7% of the population sampling frame but were oversampled to constitute Measures 15% of the mail-out sample to ensure adequate representation. Primary outcome. Our primary outcome variable was a measure of relative deprescribing authority (RDA), defined as the extent Survey Instrument to which patients afforded different providers the authority to The Patient Perceptions of Discontinuation (PPoD) instrument is discontinue a medication prescribed by another provider. The a psychometrically validated survey with 43 medication discon- measure was derived by combining responses to 2 yes/no (Y/N) tinuation–related items; it includes 8 attitudinal scales and items: (1) “Imagine that a specialist…prescribed a medicine for you. 14 patient characteristic and background items.18 It includes 3 Would you be comfortable if your PCP told you to stop taking it?” previously established multi-item scales: Beliefs about Medicines and (2) “Imagine that your VA PCP prescribed a medicine for you. Questionnaire (BMQ)–Overuse, focused on overreliance on medicines; Would you be comfortable if a VA clinical pharmacist told you to Trust–provider, assessing provider motivation; and CollaboRATE, stop taking it?” We created 4 distinct categorical RDA outcome reflecting shared decision making.19-21 Five additional PPoD scales groups: PCP-N/Pharm-N, PCP-N/Pharm-Y, PCP-Y/Pharm-N, and consist of a combination of new items and selected items from PCP-Y/Pharm-Y, where PCP or Pharm (pharmacist) indicates the pre-existing scales.22,23 Medication Concerns addresses medication provider of interest and Y/N indicates whether the respondent effects. Provider Knowledge is about the PCP’s aptitude. Interest in felt that that provider had the jurisdiction to recommend stopping Stopping Medicines assesses current deprescribing interest. Patient medications prescribed by a provider higher in the prescribing Involvement in Decision Making explores participating in medical authority hierarchy. This categorization is described in the Figure care. Unimportance of Medicines measures patients’ opinions of the (A). VA clinical pharmacists have prescribing authority and may lack of benefit and/or potential harms of their current medicines. manage patients with chronic conditions. We modified CollaboRATE responses to a scale of 1 to 5 to maintain Predictor variables. Our primary predictors of interest were consistency with other scales, where 1 equals “no effort” and 5 the 8 attitudinal scales of the PPoD survey instrument. Secondary equals “every effort.” All other PPoD scales use a 5-point response predictors included patient characteristics and experiential variables scale, where 1 equals “strongly disagree” and 5 equals “strongly (ie, items about whether the patient had ever asked their doctor to agree,” with a neutral midpoint. Each scale score is an average of stop a medicine; had seen a VA PCP, VA specialist, and/or VA clinical responses to individual items within that scale. Additional survey pharmacist in the past year; had ever received conflicting advice items address actual and hypothetical deprescribing experiences, from different providers; and had ever been told to stop a medicine).

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Analysis FIGURE. RDA Outcome Groups We verified data validity by examining item frequencies, correcting out-of-range values, and adjusting contradictory response patterns A. Creation of RDA Outcome Groups Imagine that your VA PCP for items involving screener questions or other contingencies. prescribed a medicine for you. 2 Would you be comfortable if We conducted bivariate tests of association (χ tests and t tests as a VA clinical pharmacist told applicable) between all patient characteristic and attitudinal scale you to stop taking it? variables and the 4 categorical RDA primary outcome groups. Variables Yes No with associations significant at the P <.1 level were retained for Imagine that a specialist… PCP-Y, PCP-Y, inclusion in a multinomial logistic regression to determine which Yes prescribed a medicine for you. Pharm-Y Pharm-N factors are associated with each of the 4 categorical outcome groups; Would you be comfortable if your PCP-N, PCP-N, No a stepwise approach was used to obtain the most parsimonious PCP told you to stop taking it? Pharm-Y Pharm-N model. Our null hypothesis was that there are no differences in patient characteristics or attitudes among the 4 RDA outcome groups. B. Distribution of RDA Groupsa All analyses were conducted in SAS version 9.3 (SAS Institute Inc; Cary, North Carolina). The study was approved by the VA Boston PCP-Y, Pharm-Y PCP-N, Pharm-N Healthcare System Institutional Review Board. 146 (20%) 281 (38%) RESULTS

PCP-N, Pharm-Y Characteristics of Study Sample 155 (21%) PCP-Y, Pharm-N Of the 1600 veterans in the mail-out sample, 53 were unreachable. 153 (21%) We obtained 803 surveys, for an adjusted response rate of 52%. Nonrespondents were similar to respondents with regard to race N indicates no; PCP, primary care provider; Pharm, pharmacist; RDA, relative deprescribing authority; VA, Veterans Affairs; Y, yes. and region of the country, but respondents were older (mean age, aPatterns of comfort with provider recommendations to discontinue. PCP-Y/N 67.0 vs 65.5 years; P = .01) and took slightly fewer medications indicates response to “Imagine that a specialist (like a heart doctor, kidney doctor, or psychiatrist) prescribed a medicine for you. Would you be comfort- (mean, 10.1 vs 10.5; P = .02). able if your PCP told you to stop taking it?” and Pharm-Y/N indicates response Respondents were predominantly men (85%); 68% identified as to “Imagine that your VA PCP prescribed a medicine for you. Would you be comfortable if a VA clinical pharmacist told you to stop taking it?” non-Hispanic white and 17% as non-Hispanic black (Table 1). The majority (60%) were older than 65 years, with generally poor (16%) or fair (45%) health. With respect to prescriptions, 6% reported TABLE 1. Self-Reported Respondent Characteristics and Health Status taking fewer than 5, 38% reported 5 to 8, 35% reported 9 to 12, and Respondent Characteristic (N = 803) n (%)a 21% reported 13 or more prescriptions. Self-reported health status Participant attitudes toward medications and their providers Poor 123 (15.6) were generally favorable (Table 2). Respondents generally disagreed Fair 354 (44.8) that medicines were either unimportant or overused, with mean Good 245 (31.0) scores of 2.39 and 2.91 on the Unimportance of Medicine and the Very good 61 (7.7) BMQ–Overuse scales, respectively. Respondents held generally Excellent 7 (0.9) positive views of providers, with mean scores of 3.75 on Provider Self-reported presence of medical diagnoses Knowledge and 3.56 on Trust–provider. Concurrently, patients were Anxiety 283 (35.2) generally interested in stopping medicines (mean, 3.42). Arthritis 476 (59.3) Subjects had varied experiences related to deprescribing commu- Cancer 160 (19.9) nication and decisions (Table 3). Fewer than 1 in 5 patients (18%) Chronic lung disease 226 (28.1) reported receiving conflicting medication information from different Depression 349 (43.5) providers. More than half (53%) recalled being told by a provider to Diabetes 422 (52.6) stop a medicine, and a similar proportion (55%) reported that they Heart failure 166 (20.7) had asked their doctor to stop a medicine. Just over 1 in 3 patients Hypertension 585 (72.9) (34.1%) reported actually having stopped a medicine. Ischemic heart disease 250 (31.1) Posttraumatic stress disorder 264 (32.9) Respondent Preferences and Predictors of RDA Stroke 89 (11.1) A total of 735 respondents answered both questions that were Other 156 (19.4) used to create the RDA outcome measure. As summarized in the

(continued) Figure (B), 281 (38%) were uncomfortable with both a PCP stopping

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a specialist-prescribed medication and a clinical pharmacist stop- TABLE 1. (Continued) Self-Reported Respondent Characteristics and ping a PCP-prescribed medication (PCP-N/Pharm-N). In contrast, Health Status 146 (20%) indicated that they would be comfortable with both a Respondent Characteristic (N = 803) n (%)a PCP stopping a specialist-prescribed medication and a clinical Number of prescription medications pharmacist stopping a PCP-prescribed medication (PCP-Y/Pharm-Y). 0 2 (0.3) There were 155 (21%) who said no to the PCP stopping a specialist’s 1-4 48 (6.2) medication and yes to the clinical pharmacist stopping a PCP’s 5-8 293 (37.7) medication (PCP-N/Pharm-Y), whereas 153 (21%) said yes to the 9-12 273 (35.1) PCP’s authority but no to the clinical pharmacist’s (PCP-Y/Pharm-N). ≥13 162 (20.8) Based on bivariate analyses (data not shown), variables initially Number of nonprescription medications included in the multinomial logistic regression model predicting 0 227 (28.9) RDA outcome groups were self-reported diagnosis of chronic lung 1-4 478 (60.8) disease, depression, heart failure, or ischemic heart disease; number 5-8 65 (8.3) of prescriptions; seeing a non-VA specialist; receiving conflicting 9-12 10 (1.3) advice; being told to stop a medicine; marital status; and 6 attitudinal ≥13 6 (0.8) scales (BMQ, Trust–provider, CollaboRATE, Medication Concerns, Number of healthcare provider visits in prior year Provider Knowledge, and Patient Involvement in Decision Making). 1-4 230 (29.0) In the final model, when setting the group who responded no to 5-8 224 (28.3) both questions as the reference (PCP-N/Pharm-N), several factors 9-12 123 (15.5) influenced the likelihood of being in 1 of the other 3 RDA groups ≥13 215 (27.2) (Table 4). Specifically, those with a diagnosis of chronic lung disease Admitted to a hospital in prior year 282 (35.6) were less likely to be in the PCP-Y/Pharm-N group (odds ratio [OR], Admitted to a nursing home, long-term care facility, 32 (4.1) 0.52; 95% CI, 0.31-0.88). Those indicating higher trust in their or rehabilitation facility in the prior year PCP were less likely to be in the PCP-N/Pharm-Y group (OR, 0.52; Friend or family member assistance with medicationsb 95% CI, 0.34-0.81) but more likely to be in the PCP-Y/Pharm-N (OR, Makes decisions about which medicines to take 79 (10.1) 2.16; 95% CI, 1.31-3.56) or PCP-Y/Pharm-Y groups (OR, 1.83; 95% CI, Helps manage medicines 175 (22.4) 1.13-2.98). Patients with greater concerns about medication were Helps with taking medicines 91 (11.6) more likely to be in the PCP-Y/Pharm-Y group (OR, 1.45; 95% CI, None of the above 560 (71.5) 1.09-1.92). Veterans interested in being involved in decision making Age in years about medicines were more likely to respond PCP-N/Pharm-Y (OR, ≤55 106 (13.2) 1.41; 95% CI, 1.04-1.92). 56-65 187 (23.3) 66-75 334 (41.6) DISCUSSION ≥76 151 (18.8) Male sex 659 (85.4) We conducted a national survey to assess patients’ preferences Race/ethnicity for and attitudes toward different providers discontinuing their Non-Hispanic white 548 (68.2) medications. Our primary outcome measure of RDA characterizes Non-Hispanic black 134 (16.7) 4 patient groups based on their willingness to allow clinicians to Other 97 (12.1) discontinue medications prescribed by other clinicians. Whereas Marital status some patients were willing to allow any provider to deprescribe, Single/divorced/widowed 285 (35.5) others were uncomfortable accepting such recommendations from In a relationship/married/civil union 499 (62.2) providers with different levels of expertise. Variation in patient preferences may be reflected in each of the 4 RDA groups. Education level In our study, the most common RDA group was PCP-N/Pharm-N, High school or less 367 (45.7) with 38% of respondents indicating that they would not want their Some college or more 414 (51.6) PCP to discontinue a medication prescribed by a specialist, nor aNumbers do not add up to 803 due to missing data. would they want a clinical pharmacist to discontinue a medica- bMore than 1 option may be selected. tion prescribed by the PCP. These patients may place greater value in specialists’ increased training and expertise and thus grant them preferential jurisdiction over all decisions related to their specialty.24 However, this preference might not always be realistic in the current healthcare environment in which patients often

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TABLE 2. Respondent Attitudes (N = 803) TABLE 4. Multinomial Regression Model Results Scale n Mean (SD)a PCP-N/ PCP-Y/ PCP-Y/ a a a Medication Concerns 792 3.01 (0.85) Pharm-Y Pharm-N Pharm-Y b Provider Knowledge 799 3.75 (0.82) Variable OR (95% CI) OR (95% CI) OR (95% CI) P 1.08 0.52 0.70 Interest in Stopping Medicines 801 3.42 (0.84) Chronic lung disease .044 (0.66-1.75) (0.31-0.88) (0.42-1.15) Patient Involvement in Decision Making 799 3.25 (0.79) 1.50 1.03 0.66 Unimportance of Medicines 802 2.39 (0.75) Ischemic heart disease .044 (0.94-2.40) (0.64-1.67) (0.40-1.10) Beliefs about Medicines Questionnaire–Overuse 798 2.91 (0.75) 0.89 0.71 0.53 Marriedc .051 Trust–provider 801 3.56 (0.57) (0.55-1.44) (0.45-1.13) (0.34-0.84) CollaboRATE 786 3.73 (0.99) 0.52 2.16 1.83 Trust–provider (PCP)d <.001 (0.34-0.81) (1.31-3.56) (1.13-2.98) aPossible range of scores for all scales: 1-5. 0.999 1.05 1.45 Medication concernsd .053 (0.75-1.32) (0.80-1.39) (1.09-1.92) Patient involvement 1.41 0.92 0.88 .042 TABLE 3. Respondent Healthcare Experiences (N = 803) in decision makingd (1.04-1.92) (0.69-1.23) (0.65-1.19) Respondent Experience n (%)a N indicates no; OR, odds ratio; PCP, primary care provider; Pharm, pharma- Has PCP in the community (ie, non-VA PCP) 194 (28.3) cist; Y, yes. Saw VA PCP in past 12 months 662 (97.1) aReference group is PCP-N/Pharm-N. bP value estimated for the association between the variables and the multi­ Saw VA specialist in the past 12 months 530 (79.9) nomial outcome, per the Wald test. Saw VA clinical pharmacist in the past 12 months 238 (36.4) cCompared with single/divorced/widowed. d Had prescription medicines filled at a pharmacy outside of Indicates continuous variable. the VA during the past 12 months None 491 (71.9) Patients who are more amenable to anyone discontinuing their Some to all 192 (28.1) medications may also demonstrate greater nonadherence to their Ever had one provider say one thing about a medicine and 125 (18.3) prescriptions, and streamlining their medication regimens may another provider say something different about that medicine improve adherence.27 Ever had provider recommend medication discontinuation The 2 discordant RDA groups fall somewhere in the middle. No 231 (35.0) Patients comfortable with the PCP discontinuing a specialist’s Not sure or can’t remember 77 (11.7) medication but not with the clinical pharmacist making the same Yes 353 (53.4) recommendation (PCP-Y/Pharm-N; 21%) may view their PCP as having Ever asked provider to discontinue medication 383 (55.0) ultimate responsibility for their care, with final decision-making PCP indicates primary care provider; VA, Veterans Affairs. authority. This attitude may result from trust, confidence in the aNumbers do not add up to 803 due to missing data. PCP’s medical knowledge, familiarity with their PCP, or concerns about needing 1 provider to oversee everything.25,28,29 In our study, receive care from multiple providers.9 Patients may also feel that patients with chronic lung disease were less likely to respond PCP-Y/ the original prescriber should maintain authority because of Pharm-N, perhaps reflecting that they may regularly see a specialist concerns that another clinician lacks the information required to (eg, a pulmonologist) for this condition, which leads patients to not make a medically sound deprescribing recommendation.25 This want the PCP to change the specialist’s medications. reluctance may be justified given that having multiple providers The other discordant RDA outcome group has the opposite can be a safety concern9 and optimal coordination among PCPs response pattern, with patients unwilling to allow the PCP to and specialists often remains elusive. Improving communication discontinue a specialist’s medication but amenable to a clinical among clinicians could alleviate this potential patient concern. pharmacist deprescribing a PCP’s medication (PCP-N/Pharm-Y; At the other end of the spectrum, patients who are comfortable 21%). Several factors in a patient–provider relationship influence with both their PCP and a clinical pharmacist deprescribing a the level of trust in a particular provider, such as duration, gender medication prescribed by someone with more expertise (PCP-Y/ and/or racial concordance, provider level of expertise, or other Pharm-Y; 20%) may generally prefer fewer medications, welcoming intangible qualities,30-32 ultimately affecting whether a patient is any opportunity to reduce their number. Respondents with greater comfortable with the PCP deprescribing a specialist’s prescription. medication concerns were more likely to be in this group and thus Other possible reasons for the PCP-N/Pharm-Y pattern focus may be more proactive in asking providers about stopping medicines. on the pharmacist. Patients may view the clinical pharmacist as Efforts to reduce can capitalize on this patient an extension of the PCP, acting as part of the Patient-Aligned Care characteristic, and activating the patient to question the continued Team (the VA’s patient-centered medical home) with prescribing need of a medication can lead to discontinuation attempts.26 authority on par with PCPs. In a survey of older Canadian adults,

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51% were comfortable, 25% unsure, and 19% uncomfortable with role, with a substantial percentage of patients expressing comfort pharmacists having a role in deprescribing.33 In comparison, our with pharmacists managing their medications. study had fewer patients reporting comfort with clinical pharmacists deprescribing, but this may result from not explicitly stating that Limitations PCPs would be informed of decisions; doing so may have reassured Our study is not without limitations. We surveyed veterans actively the respondent. Another potential explanation for patients’ comfort using the VA healthcare system, and results may not generalize with clinical pharmacists deprescribing may be related to the to non-VA settings. These participants were predominantly men, nature of their interactions, such as spending more time together and gender differences may influence healthcare attitudes. Also, reviewing patients’ medications and their indications, as well as veterans’ experience with the military hierarchy may influence their discussing strategies for medication adherence. Patients with more attitudes as patients in any medical system; a civilian population may interest in participating in medication-related decision making respond differently. However, research within community settings were more likely to be in this PCP-N/Pharm-Y group, reflecting has shown that patients ascribe different roles and responsibilities that interactions with pharmacists may afford more opportunity to clinical team members (eg, specialist, PCP, pharmacist, nurse), in for patients to express their wishes. essence creating hierarchies.33 It is also possible that the national Our findings have multiple implications for safe and appropriate health system of the VA, including a single electronic health record, medication deprescribing. An overarching theme is that for the leads patients to believe that their care is more coordinated than many patients who receive care from multiple providers, whether elsewhere. Nonetheless, many veterans use both VA and non-VA within or across healthcare systems, coordination and communi- care and remain subject to the same gaps in communication that cation among providers is essential, and many patients assume happen for nonusers of the VA. Another potential limitation to the this occurs regularly and efficiently. However, given the known generalizability of our findings is that clinical pharmacists within difficulties associated with reliance on the electronic health record VA have a scope of practice whereby they can prescribe, monitor, to accomplish this coordination,34,35 as well as providers’ perception and perform other activities to facilitate patient care. Pharmacists that more communication is needed,36 communication systems in non-VA settings may or may not be empowered to perform these need to be developed and implemented to reduce the risks associ- activities, depending on the terms of their collaborative practice ated with having multiple prescribers. Further, efforts to develop agreements. Regardless, implementation of medical homes nationally deprescribing clinics, which may introduce another clinician into will require all team members to work at the top of their license, and the patient’s care, should recognize patient interest and comfort in thus findings within VA are relevant elsewhere. Finally, the survey knowing that their providers are communicating with one another. questions were asked in a hypothetical and general manner; it is The frequency and quality of professional communication may also possible that patients would respond differently in actual clinical influence clinicians’ perception of the scope of their deprescribing scenarios with specific medications. Additional work examining jurisdiction. One possibility is that clinicians’ discomfort with or outcomes from clinical encounters should be conducted. potential unwillingness to take on the additional workload associ- ated with deprescribing is unintentionally imparting these same hierarchical views to patients. Efforts to increase the confidence of CONCLUSIONS all clinicians to practice at the top of their license may improve the Inappropriate medication use places patients at risk of harm, frequency with which deprescribing recommendations are made burdening patients and the healthcare system. Efforts to improve the and increase the trust patients place in clinicians of all training to rational use of medicine should include support for deprescribing, provide high-quality and high-value treatment. but if patients are unwilling to accept recommendations to stop a As clinical pharmacists expand their scope of practice, many have medication from a particular provider, these efforts will fail. Moreover, advocated for their integration into varied care settings, broadening because deprescribing could be considered a “preference-sensitive the benefit they provide.37,38 Inclusion of pharmacists on teams can decision,”41 incorporating patient attitudes and preferences about lead to more appropriate medication use and fewer adverse drug medications may also mitigate clinicians’ concerns about patient events.39 Specific to the focus of our study, Twigg et al found that resistance to deprescribing.11,42 Understanding patient preferences pharmacists often identify medications that are appropriate to related to medication prescribing and attitudes toward RDA can deprescribe.40 However, in that study, pharmacists only made recom- ultimately facilitate effective design and implementation of mendations; they did not enact the decisions. With the expansion deprescribing interventions. n of prescribing—and thus deprescribing—authority to pharmacists, it will be important to ensure that they feel empowered to enact Acknowledgments The authors thank Rachel Lippin-Foster, BA, for her assistance in the manage- decisions; that other clinicians “higher” in the prescribing hierarchy ment of the survey. do not feel undermined by such actions; and, just as critically, that patients are receptive to receiving such recommendations from Author Affiliations: Section of General Internal Medicine (AL), Center for Healthcare Organization and Implementation Research (CHOIR) (AL, KS, SRS), pharmacists. Our study provides support for an expanded pharmacist and Geriatrics and Extended Care (SRS), VA Boston Healthcare System, Boston,

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MA; Section of General Internal Medicine, Boston Medical Center (AL), Boston, 16. Mossialos E, Courtin E, Naci H, et al. From “retailers” to health care providers: transforming the MA; Veterans Health Administration Office of Reporting, Analytics, Performance, role of community pharmacists in chronic disease management. Health Policy. 2015;119(5):628-639. Improvement and Deployment (MM), Bedford, MA; Department of Health Law, doi: 10.1016/j.healthpol.2015.02.007. Policy & Management, Boston University School of Public Health (MM, BGB), 17. Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Boston, MA; CHOIR, ENRM Veterans Affairs Medical Center (BGB), Bedford, MA. Couns. 2015;98(2):220-225. doi: 10.1016/j.pec.2014.11.010. 18. Linsky A, Simon SR, Stolzmann K, Bokhour BG, Meterko M. Prescribers’ perceptions of medication discon- Source of Funding: This study was funded by VA Health Services Research & tinuation: survey instrument development and validation. Am J Manag Care. 2016;22(11):747-754. Development (CDA 12-166), which had no role in the study’s design and conduct; 19. Horne R, Weinman J, Hankins M. The Beliefs about Medicines Questionnaire: the development and evalua- collection, management, analysis, and interpretation of the data; preparation, tion of a new method for assessing the cognitive representation of medication. Psychol Health. 1999;14(1):1-24. review, or approval of the manuscript; nor decision to submit the manuscript doi: 10.1080/08870449908407311. for publication. 20. Gordon HS, Street RL Jr, Sharf BF, Kelly PA, Souchek J. Racial differences in trust and lung cancer patients’ Prior Presentation: This study was presented in poster format at the Society perceptions of physician communication. J Clin Oncol. 2006;24(9):904-909. doi: 10.1200/JCO.2005.03.1955. for General Internal Medicine Annual Meeting in Washington, DC (April 2017), 21. Elwyn G, Barr PJ, Grande SW, Thompson R, Walsh T, Ozanne EM. Developing CollaboRATE: a fast and and at the AcademyHealth Annual Research Meeting in New Orleans, LA (June frugal patient-reported measure of shared decision making in clinical encounters. Patient Educ Couns. 2017), as well as in oral format at the Lown Conference in Boston, MA (May 2017). 2013;93(1):102-107. doi: 10.1016/j.pec.2013.05.009. Author Disclosures: The authors report no relationship or financial interest 22. Ende J, Kazis L, Ash A, Moskowitz MA. Measuring patients’ desire for autonomy: decision making and with any entity that would pose a conflict of interest with the subject matter of information-seeking preferences among medical patients. J Gen Intern Med. 1989;4(1):23-30. this article. 23. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. 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