Avoidable hospitalizations due to adverse drug events and high-risk prescribing are common in older people. Primary care physicians prescribe most on-going medicines. Deprescribing has long been ...essential to best prescribing practice. We sought to explore the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice to inform the development of an intervention to support safer prescribing.
We used a snowball sampling technique to identify potential participants. Physicians were selected on the basis of years in practice, employment status, and practice setting, with an additional focus on information-rich participants. Twenty-four semistructured interviews were audio-recorded, transcribed verbatim, and analyzed to identify emergent themes.
Physicians described deprescribing as "swimming against the tide" of patient expectations, the medical culture of prescribing, and organizational constraints. They said deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient. Physicians recommended organizational changes to support safer prescribing, including targeted funding for annual medicines review, computer prompts, improved information flows between prescribers, improved access to expert advice and user-friendly decision support, increased availability of non-pharmaceutical therapies, and enhanced patient engagement in medicines management.
Interventions to support safer prescribing in everyday practice should consider the sociocultural, personal, relational, and organizational constraints on deprescribing. Regulations and policies should be designed to support physicians in practicing according to their professional ethical values.
In assessing overseas-trained general practitioners (GPs) applying for specialist recognition in Australia, the Royal Australian College of General Practitioners (RACGP) sets a minimum requirement of ...2 days per week ‘undertaking general practice activities’ over the 3 years prior to application. The RACGP does not consider academic practice (i.e. relevant teaching and research) to be a ‘general practice activity’, thereby blocking overseas-trained full-time academic GPs from specialist recognition in Australia. The actions of the RACGP have implications for access to quality primary health care in Australia.
Summary
Clinicians must make decisions amid the uncertainty that is ubiquitous to clinical practice.
Uncertainty in clinical practice can assume many forms depending on its source, such as ...insufficient personal knowledge or scientific evidence, limited practical understanding or competence, challenging interpersonal relationships, and complexity and ambiguity in clinical encounters.
The level and experience of uncertainty varies according to personal traits, clinical context, affective factors and sociocultural norms.
Clinicians vary in their tolerance of uncertainty, and maladaptive responses may adversely affect patient care and clinician wellbeing.
Various strategies can be used to minimise and manage, but not eliminate, uncertainty and to share uncertainty with patients without compromising the clinician–patient relationship or clinician credibility.
Abstract
Background
Many people experience withdrawal symptoms when they attempt to stop antidepressants. Withdrawal symptoms are readily misconstrued for relapse or ongoing need for medication, ...contributing to long-term use (> 12 months). Long-term antidepressant use is increasing internationally yet is not recommended for most people. Long-term use is associated with adverse effects including weight gain, sexual dysfunction, lethargy, emotional numbing and increased risk of falls and fractures. This study aims to determine the effectiveness of two multi-strategy interventions (RELEASE and RELEASE+) in supporting the safe cessation of long-term antidepressants, estimate cost-effectiveness, and evaluate implementation strategies.
Methods
Design
3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1. Setting: primary care general practices in southeast Queensland, Australia. Population: adults 18 years or older taking antidepressants for longer than 1 year. Practices will be randomised on a 1.5:1:1 ratio of Usual care:RELEASE:RELEASE+. Intervention: RELEASE for patients includes evidence-based information and resources and an invitation to medication review; RELEASE for GPs includes education, training and printable resources via practice management software. RELEASE+ includes additional internet support for patients and prescribing support including audit and feedback for GPs. Outcome measures: the primary outcome is antidepressant use at 12 months self-reported by patients. Cessation is defined as 0 mg antidepressant maintained for at least 2 weeks. Secondary outcomes: at 6 and 12 months are health-related quality of life, antidepressant side effects, well-being, withdrawal symptoms, emotional numbing, beliefs about antidepressants, depressive symptoms, and anxiety symptoms; and at 12 months 75% reduction in antidepressant dose; aggregated practice level antidepressant prescribing, and health service utilisation for costs. Sample size: 653 patients from 28 practices. A concurrent evaluation of implementation will be through mixed methods including interviews with up to 40 patients and primary care general practitioners, brief e-surveys, and study administrative data to assess implementation outcomes (adoption and fidelity).
Discussion
The RELEASE study will develop new knowledge applicable internationally on the effectiveness, cost-effectiveness, and implementation of two multi-strategy interventions in supporting the safe cessation of long-term antidepressants to improve primary health care and outcomes for patients.
Trial registration
ANZCTR, ACTRN12622001379707p. Registered on 27 October 2022.
The 'Mental health: Productivity Commission inquiry report' (2020) recommended as a 'priority reform' that we 'address adverse outcomes from prescribing practices of mental health medication'. The ...report states that ‘while antipsychotic prescribing in aged care facilities is one element of this... arguably a greater concern, given its frequency, is antidepressant prescribing’. The report recommends that general practitioner (GP) 'mental health training and professional development' be improved to increase 'adherence to evidence-based clinical practices (including the clinical appropriateness of GP’s sic prescribing practices for mental health medication, management of medication side effects and de-prescribing)'. This article discusses antidepressant prescribing in Australian general practice, adverse drug effects and withdrawal symptoms, and the changes we might make to improve patient outcomes.
Older adults should be supported to make informed decisions about cancer screening. However, it is unknown how general practitioners (GPs) in Australia communicate about cancer screening with older ...people.
To investigate GPs' views and experiences of communicating about cancer screening (breast, cervical, prostate, and bowel) with older people (≥70 years).
Qualitative, semi-structured interviews, Australia.
Interviews were conducted with GPs practising in Australia (n = 28), recruited through practice-based research networks, primary health networks, social media, and email invitation. Interviews were audio-recorded and analysed thematically using Framework Analysis.
Findings across GPs were organized into 3 themes: (i) varied motivation to initiate cancer screening discussions; some GPs reported that they only initiated screening within recommended ages (<75 years), others described initiating discussions beyond recommended ages, and some experienced older patient-initiated discussions; (ii) GPs described the role they played in providing screening information, whereby detailed discussions about the benefits/risks of prostate screening were more likely than other nationally funded screening types (breast, cervical, and bowel); however, some GPs had limited knowledge of recommendations and found it challenging to explain why screening recommendations have upper ages; (iii) GPs reported providing tailored advice and discussion based on personal patient preferences, overall health/function, risk of cancer, and previous screening.
Strategies to support conversations between GPs and older people about the potential benefits and harms of screening in older age and rationale for upper age limits to screening programmes may be helpful. Further research in this area is needed.
There is increasing evidence for the potential benefits and harms of cardiovascular disease (CVD) medications in older people (>75 years) prompting updating of clinical guidelines. We explored the ...views of older people about CVD medication to inform guideline development.
Qualitative study using semistructured interviews and focus groups. An ethnically diverse group of community dwelling older people were purposefully recruited from northern New Zealand using flyers in primary care clinics, local libraries, social groups, and places of worship, and by word of mouth. Interviews and focus groups were digitally recorded, transcribed verbatim, and analysed using an iterative and inductive approach to thematic analysis.
Thirty-nine participants from 4 ethnic groups were recruited (mean 74 years; range 61-91 years; Māori (7), South Asian (8), European (9), and Pasifika (15)). Most participants were taking CVD medication/s. Four main themes emerged: (i) emphasizing the benefits of CVD medication and downplaying the harms; (ii) feeling compelled to take medication; (iii) trusting "my" doctor; and (iv) expecting medication to be continued.
Findings raise questions about older people's agency in decision-making regarding CVD medication. CVD risk management guidelines for older people could include strategies to support effective communication of the potential benefits and harms of CVD medication in older people, balancing life expectancy, and the expected duration of therapy.
Background and objective Some general practitioners (GPs) find the older driver medical assessment challenging, citing clinical uncertainty and concerns about communicating the need for further ...testing or driving cessation while maintaining a trusting therapeutic relationship. A screening toolkit could help support GP decision making and communication about fitness to drive. The aim of this study was to investigate the feasibility, acceptability and utility of the 3-Domains screening toolkit for the medical assessment of older drivers in Australian general practice.
Methods A prospective mixed-methods study was conducted in nine general practices in south-east Queensland. Participants were older drivers (age >=75 years) attending annual driving licence medical assessment, GPs and practice nurses. The 3-Domains toolkit comprises three screening tests (Snellen chart visual acuity, functional reach, road signs recognition). We evaluated the feasibility, acceptability and utility of the toolkit.
Results Practices used the toolkit in 43 older driver medical assessments (age 75-93 years; combined predictive score 13-96%). Twenty-two semistructured interviews were conducted. Older drivers felt reassured by the thorough assessment. GPs said the toolkit fitted into practice workflows, informed clinical judgement and supported conversations about fitness to drive while preserving therapeutic relationships.
Discussion The 3-Domains screening toolkit is feasible, acceptable and useful for the medical assessment of older drivers in Australian general practice.
PDF
