Geriatric Care 2020; volume 6:8703

General practitioner attitudes medications, however almost half expressed and confidence to deprescribing doubts regarding deprescribing when Correspondence: Pier Riccardo Rossi, Scuola medication was initially prescribed by a Piemontese di Medicina Generale; Società for elderly patients colleague (45%) or when patient and/or Italiana di Medicina Generale e delle Cure caregiver supported the opportunity to Primarie; General Practitioner, Torino Local Health Authority, via Emilio Ghione 40, Pier Riccardo Rossi,1-3 Sarah E. Hegarty,4 continue the assumption (49%). Around a 5 6 10156 Torino, Italy. Vittorio Maio, Marco Lombardi, third of doctors maintain that the absence of E-mail: [email protected] Andrea Pizzini,1-3 Aldo Mozzone,1-3 strong evidence supporting deprescribing Marzio Uberti,1-3 Simonetta Miozzo1,2,7 prevents them from considering it (38%), Key words: Deprescribing; general practi- that they do not have the necessary time to tioner; attitude; primary care; elderly. 1Scuola Piemontese di Medicina 2 effectively go through the process of Generale, Torino, Italy; Società Italiana deprescribing (29%), and that fear of Acknowledgments: we thank for their contri- di Medicina Generale e delle Cure possible effects due on withdrawal prevents bution the following tutors of the Scuola Primarie, Torino, Italy; 3General Piemontese di Medicina Generale: Caposieno them from deprescribing (31%). There was M, Araldi M, Boella G, Fassone R, Piano P, Practitioner, Torino Local Health no strong correlation between physicians’ 4 Torta F, Morato P, Di Gravina G, Rumore A, Authority, Torino, Italy; Division of confidence and attitudes or barriers Vitali S, Mandas R, Bianchi S, Raiteri G. Biostatistics, Department of associated with deprescribing. Pharmacology and Experimental The present study confirms that general Contributions: the authors contributed equally. Therapeutics, Thomas Jefferson practitioners sense the importance of deprescribing and feel prepared to face it Conflict of interest: the authors declare no University, Philadelphia, PA, USA; potential conflict of interest. 5College of Population Health, Thomas managing communication with patients and Jefferson University, Philadelphia, PA, caregivers, but find barriers when enacting Received for publication: 2 December 2019. USA; 6Parma Local Health Authority, the practice in a real-life context. Revision received: 19 January 2020. Parma, Italy; 7General Practitioner, Accepted for publication: 24 Janauary 2020. Pinerolo-Collegno Local Health onlyThis work is licensed under a Creative Authority, Pinerolo-Collegno (TO), Italy How this fits in Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). Data about physicians’ confidenceuse and ©Copyright: the Author(s), 2020 attitudes toward deprescribing are limited. Licensee PAGEPress, Italy Abstract This study found that general practitioners Geriatric Care 2020; 6:8703 recognize the importance of deprescribing doi:10.4081/gc.2020.8703 Deprescribing is a patient-centered and feel comfortable to undertake the process of medication withdrawal intended deprescribing process with patients and to achieve improved health outcomes caregivers. However, several barriers when through discontinuation of one or more enacting the practice in a real-life context detrimental pharmacological interactions, medications that are either potentially were identified. Study results can be used to falls, decreased cognitive function,2,3 and the harmful or no longer required. plan educational and training activities for decrease in potential pharmacological The objective of this study was to assess primary care physicians and other health benefits. the perceptions of primary care physicians care professionals involved in the Guidelines motivating drug prescription on deprescribing and potential barriers to medication prescription process, as well as derive from case studies on single deprescribing in the Local Health Authority to design strategies for improving patients’ pathologies and in most cases on selected (LHA) of Turin, Piedmont, Italy. Secondary understanding of appropriate use of populations: this approach immediately objective was to evaluate educational needs medications. In addition, these results can excludes polymorbid and/or elderly of primary care physician. provide useful elements for political patients.4-6 It can therefore be said that Cross sectional survey of primaryNon-commercial care decision-makers and for those who are polypharmacy on elderly patients often physicians working in the LHA of Turin, delegated to organize healthcare services for represent isolated experiments.7 The Piedmont, Italy. the elderly. challenge is to establish, based on each 439 GPs (71.3% of the total number of individual patient, whether it is possible to primary care physicians) attended an introduce a new medication or to deprescribe educational session related to deprescribing one based on the current health situation and were asked to anonymously answer a Introduction while also respecting the patient’s and paper survey. Participants were asked to caregiver’s preferences. complete a previously published questionnaire Polypharmacy is an ever-growing Polypharmacy must, therefore, be about deprescribing and potential factors healthcare issue, mainly common in elderly monitored and constantly adapted to the affecting the deprescribing process. patients. While it can sometimes be patient’s needs over time. All healthcare A correlation coefficient was calculated necessary and motivated by multimorbidity,1 practitioners should consider the positive to assess the association between physicians’ polypharmacy can still represent an issue for and negative potential of polypharmacy, but confidence in deprescribing and attitudes or at least two main reasons: the risk of the best-suited figures to take care of the barriers associated with deprescribing. pharmacological interactions and adverse problem are General Practitioners (GPs) who Many GPs (71%) reported general reactions (ADR) on the one hand and a operate in the context of primary care and confidence in their ability to deprescribe. decrease in compliance (adherence to the are ultimately in charge of caring for the Most respondents (83%) reported they were therapy) on the other hand. Consequences person and have knowledge of their history comfortable deprescribing preventive can be excessive hospitalization because of and quality of life.

[Geriatric Care 2020; 6:8703] [page 1] Article

Deprescribing has recently been defined such as suspension of a drug for either deprescribing, however almost half as follows: a patient-centered process of preventive or therapeutic use, the ability to expressed doubts regarding deprescribing medication withdrawal intended to achieve motivate patients towards deprescribing, and when medication was initially prescribed by improved health outcomes through the barriers to deprescribing. Doctors were a colleague (45%) or when patient and/or discontinuation of one or more medications asked to indicate the degree to which they caregiver supported the opportunity to that are either potentially harmful or no agreed with the nine statements using a continued use of said drugs (49%). Around longer required.8 Such a process can very Likert-type scale ranging from 1 (highly a third of doctors maintain that the absence well be referred to the concept of Quaternary disagree) to 7 (strongly agree). of strong evidence supporting deprescribing Prevention (P4).9 P4 is defined as: Actions During the year 2018 a group of tutors prevents them from considering it (38%), taken to identify a patient or a population at instructed by the Scuola Piemontese di that they do not have the necessary time to risk of over-medicalization, to protect Medicina Generale (School of General effectively go through the process of him/her from invasive medical procedures, medicine in Piedmont) developed and deprescribing (29%), and the fear of possible and to offer them ethically and medically presented an educational program on effects brought on from the interruption of acceptable treatment procedures.10 P4 is a deprescribing sponsored by the Turin LHA. said drugs could possibly prevent them from critical look at medical activities with an The seminars, held over the course of two deprescribing (31%). (Table 3). emphasis on the need not to harm.11 and is evenings, were mandatory and took place Correlation analyses between the first consider by WONCA a task for GPs.9 Some within the context of monthly team meetings statement and other statements revealed a studies evaluated the effectiveness of from April 2018 to November 2018. The weak correlation between perceived level of deprescribing, finding improved quality of questionnaire was voluntary and anonymous expertise and the ability to deprescribe life and no association to significant risks or and was presented at the beginning of the medication initially prescribed by another withdrawal symptoms.12,13 Of the potential second evening (October-November 2018). colleague (fifth statement, rho=0.33) and the benefits, there are still many obstacles that All answers were collected on paper and ability to motivate the patient to begin the make deprescribing difficult for physicians. then keyed into an excel spreadsheet. process of deprescribing ( ninth statement, Some studies highlight how the lack of time, Descriptive statistics were calculated to rho= 0.33) (Table 4.) Overall, there was no difficulty communicating with caregivers, summarize responses to the nine items. statisticallyonly significant association between patients and other healthcare practitioners, Pearson’s correlation coefficients were sex of the participants and the probability fragmental medical care, patients’ and calculated to determine the relationship that they will agree to any of these physicians’ conservatism/inertia and the lack between the first question (Q1) on the statements. However, older doctors (over 60) of guidelines for suspension criteria can doctor’s faith in deprescribing and all other show a greater willingness to agree with the hinder the process.14-17 Evidence suggests questions regarding attitudes or barriersusefollowing statements: In elderly patients, that using a patient-centered approach and associated with deprescribing. To simplify lack of robust evidence in favor of including patient’s perspective into the interpretation, the original 7-point scales was continuation or cessation of preventive decision making process are key elements dichotomized; responses of 5, 6 and 7 medications prevents me from deprescribing for deprescribing in the elderly population.18 strongly agree were grouped in one category (P=0.003), and Although in certain The present study aims to determine declaration of agreement, while items 1 situations I may consider appropriate whether the general practitioner’s perception strongly disagree, 2, 3 and 4 were grouped deprescribing medications in my elderly and recognition of obstacles could in a declaration of disagreement category. patients, I do not consider it for fear of potentially hinder the use of the Associations between demographic adverse drug withdrawal effects (P=0.046). deprescribing process. A secondary aim is to information about GPs (age, sex, Specialised doctors show less willingness, detect eventual educational needs of general specialization) and agreement or compared to other colleagues, to agree with practitioners or organisational deficiencies disagreement on each question in the survey the statement: I do not have the necessary within the field of primary care giving. were evaluated using logistic regression. A time to spend with my elderly patients and/or value of P<0.05 has been considered caregivers to effectively undertake the statistically relevant in all analyses. All process of deprescribing medications even analyses were conducting using SAS 9.4 though I consider it important (P=0.008) Materials and methods Non-commercial(SAS Institute Inc., Cary, NC, USA). (data not shown).

The study is based on a cross sectional survey. The population studied is made up of GPs working in the Local Health Authority Results Discussion (LHA) of Turin, Piemonte, Italy. The Summary population is made up of 616 doctors A total of 439 GPs completed the survey The results of the present study confirm entrusted in the care of a population of about (71.3% of the total number of primary care that there are inconsistencies between actual 900,000 people. We employed a published physicians in Turin). The average age was understanding and perceived knowledge questionnaire developed and used for a 59.1 years (SD: 6.1). A little over half of GPs from prescribers regarding the process of similar research conducted in the LHA of were women (51.4%) (Table 1). 32% of GPs deprescribing and the ability to put the Parma, Italy.19 We received the original reported a specialization. Complete answers process into action.19 In fact, even though Italian version of the nine-item questionnaire to the survey are reported in Table 2. The most doctors declare to understand and agree from the authors. In essence, the statement with the highest average with the concept of deprescribing, the questionnaire was designed to evaluate agreement score was: When the life responses to statements regarding their attitudes and detect levels of confidence in expectancy of my elderly patients no longer approach to it and its difficulties demonstrate doctors regarding deprescribing for elderly justifies potential benefits, I am in favor of the presence of a certain hesitation or patients. The nine statements in the deprescribing preventive medications. difficulty in tackling and bringing into action questionnaire explore deprescribing issues Nearly 70% of GPs feel prepared to tackle the completion of deprescribing while also

[page 2] [Geriatric Care 2020; 6:8703] Article facing the difficulties presented by the response rate, we do not have responses of Comparison with existing literature context of daily practice. other GPs in Turin LHA who chose not to Previous research has demonstrated the participate and, thus, cannot evaluate their effectiveness of the process in the reduction Strengths and limitations beliefs for consistency with the study of outcomes such as mortality, This study expands our knowledge on sample. Those GPs who decided to hospitalization, falls, cognitive physicians’ perception on deprescribing and complete the questionnaire may have been impairment;16-20 nonetheless, in practical more interested in the subject of related barriers. The high survey response terms, deprescribing is limited by the fear of deprescribing than those who decided not to rate makes the study results robust. adverse effects caused by discontinuation, participate. Lastly, limitations of the survey However, there are some limitations worth tools exist as they were previously reported beliefs of the patient or caregiver, or fear of noting. The survey was administered to by its authors:19 the small number of items clashing with other doctor’s prescription. primary care physicians in a specific LHA may not be able to explore a complex and Most doctors expressed agreement with within Italy, and therefore the results cannot multifaceted problem such as physician’s deprescribing preventive medication; be generalized to the overall population of attitude to deprescribing. Additionally, however, fewer agreed with deprescribing primary care physicians in Italy or wording for some questions may have guideline-recommended therapeutic elsewhere. Data were self-reported and become complex and subject to multiple medications in patients with low life therefore subject to bias. Despite a high interpretations. expectancy. When comparing the two

Table 1. Characteristics of respondents (N=439). Age, mean (SD) 59.1 (6.1) Age, N (%) only <50 20 (4.7) 50-59 179 (41.6) 60-69 231 (53.7) Sex, N (%) use Female 218 (51.4) Male 206 (48.6) Specialty, N (%) No 298 (68.0) Yes 140 (32.0)

Table 2. Percentage of physicians- reported attitudes and barriers to deprescribing. Item Strongly Strongly disagree agree 1 2 3 4 5 6 7 Q1. From a clinical standpoint, I feel confident with deprescribing in my elderly patients 0.9 2.1 5.3 22.6 30.1 26.3 12.8 Q2. When the life expectancy of my elderlyNon-commercial patients no longer justifies potential benefits, 2.1 2.7 4.8 7.5 14.6 30.4 37.9 I am in favor of deprescribing preventive medications Q3. In elderly patients with poor life expectancy, it would be appropriate to consider 5.5 9.7 12.9 16.6 19.8 22.4 13.1 deprescribing therapeutic medications even though they are recommended by guidelines Q4. In elderly patients, lack of robust evidence in favor of continuation or cessation 9.2 15.0 16.8 21.0 16.6 15.4 6.0 of preventive medications prevents me from deprescribing Q5. In my elderly patients, I have no hesitation in deprescribing medications initially 7.8 9.4 10.5 17.4 16.7 23.7 14.6 prescribed by another physician Q6. I do not have the necessary time to spend with my elderly patients and/or caregivers 20.6 21.5 15.3 13.9 13.7 10.9 4.2 to effectively undertake the process of deprescribing medications even though I consider it important Q7. I have no problem in deprescribing medications even if my elderly patients and/or 4.8 10.3 12.6 21.1 18.3 22.7 10.3 caregivers believe continuation is needed Q8. Although in certain situations I may consider appropriate deprescribing medications 13.1 20.5 17.5 17.5 15.6 13.1 2.8 in my elderly patients, I do not consider it for fear of adverse drug withdrawal effects Q9. I have no difficulty to motivate my elderly patients and/or caregivers in order to engage 2.3 4.1 7.6 11.9 21.1 33.2 19.9 them in the process of deprescribing medications For this manuscript, the original survey instrument developed in Italian has been translated into English according to the WHO guidelines (source: http://www.who.int/substance_abuse/research_tools/translation/en/)

[Geriatric Care 2020; 6:8703] [page 3] Article

statements regarding preventive and think that they have the necessary Almost 45% of doctors (statement 3) hesitate medications (second and fourth) one could understanding (statement 1), the ability to to deprescribe therapeutic medications that argue that the very high acceptance of the communicate with and motivate their are recommended by guidelines, despite the principle clashes with the perceived lack of patients (statement 9) and the time to do it fact that the elderly, those with more than information regarding timelines and (statement 6) but are prevented from one condition and those who are more likely manner of deprescribing in traditional applying it because of various external to be affected by polypharmacy are under- guidelines. Another explanation could be factors. This observation confirms a survey represented in the case studies that the the fear of adverse effects brought by presented to pharmacists, nurses, and doctors guidelines are based on.9 withdrawal, as well as the fact that the by Kouladian which demonstrated the Similarly to the results of the previous therapy might have been suggested by population’s tendency to attribute to other study conducted in the Parma LHA,19 in our another doctor. professionals rather than granting study almost half of the doctors agree on the Admittedly, prescriptions made by themselves the responsibility of fact that the faith in medication that patients different doctors who have no direct contact deprescribing.22 This same attitude has been and caregivers have represents an obstacle to between themselves for the same patient is identified as the cause of prescriptive the implementation of deprescribing. regarded in the literature as a risk factor for impropriety by Howard Brody who, Throughout the study, it is highlighted that polypharmacy and is considered an obstacle launching the top five list provocation, called patients and caregivers fear adverse effects to deprescribing.20-24 Considering statements all healthcare professionals to evaluate what due to withdrawal of medication and claim 1, 2, 6 and 9, doctors appear to agree with can be changed in one’s approach and in that there are more benefits than risks in the concept of deprescribing (statement 2) one’s own field, not in someone else’s.25,26 continuing polypharmacy.25,26

Table 3. Percentage of physician Agree (answer 5, 6 or 7 to item). Item only Agree N % Q1. From a clinical standpoint, I feel confident with deprescribing in my elderly patients 303 69.2 Q2. When the life expectancy of my elderly patients no longer justifies potential benefits, I am in favor of deprescribing preventive 363 82.9 medications use Q3. In elderly patients with poor life expectancy, it would be appropriate to consider deprescribing therapeutic medications even though 240 55.3 they are recommended by guidelines Q4. In elderly patients, lack of robust evidence in favor of continuation or cessation of preventive medications prevents me from 165 38.0 deprescribing Q5. In my elderly patients, I have no hesitation in deprescribing medications initially prescribed by another physician 241 55.0 Q6. I do not have the necessary time to spend with my elderly patients and/or caregivers to effectively undertake the process 124 28.7 of deprescribing medications even though I consider it important Q7. I have no problem in deprescribing medications even if my elderly patients and/or caregivers believe continuation is needed 224 51.3 Q8. Although in certain situations I may consider appropriate deprescribing medications in my elderly patients, I do not consider 137 31.5 it for fear of adverse drug withdrawal effects Q9. I have no difficulty to motivate my elderly patients and/or caregivers in order to engage them in the process of deprescribing 324 74.1 medications

Table 4. Correlation between questionNon-commercial related to physicians’ confidence about deprescribing (Q1) and questions related to physicians’ attitudes/barriers (Q2-Q9). RHO P Q2. When the life expectancy of my elderly patients no longer justifies potential benefits, I am in favor of deprescribing preventive 0.25 <0.01 medications Q3. In elderly patients with poor life expectancy, it would be appropriate to consider deprescribing therapeutic medications even 0.21 <0.01 though they are recommended by guidelines Q4. In elderly patients, lack of robust evidence in favor of continuation or cessation of preventive medications prevents me from 0.01 0.83 deprescribing Q5. In my elderly patients, I have no hesitation in deprescribing medications initially prescribed by another physician 0.33 <0.01 Q6. I do not have the necessary time to spend with my elderly patients and/or caregivers to effectively undertake the process –0.02 0.71 of deprescribing medications even though I consider it important Q7. I have no problem in deprescribing medications even if my elderly patients and/or caregivers believe continuation is needed 0.25 <0.01 Q8. Although in certain situations I may consider appropriate deprescribing medications in my elderly patients, I do not consider it –0.08 0.09 for fear of adverse drug withdrawal effects Q9. I have no difficulty to motivate my elderly patients and/or caregivers in order to engage them in the process of deprescribing 0.33 <0.01 medications

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