Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to ...assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe.
We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness.
Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81).
The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.
Switzerland lacks future general practitioners (GPs). Residents who wished to specialize as general practitioners were formerly trained solely in hospital settings. To better prepare and also attract ...more young doctors to become GPs, the canton of Bern (equivalent to a state) has implemented a partly state-funded vocational training program in GP practices. Our study examines the efficacy of this 10-year program, identifies factors that positively influence residents in their decision to become a GP and the distribution of new GPs in the canton of Bern, who had taken part in the traineeship. This cross-sectional survey among all residents, who participated in a traineeship in general practice from 2008 to 2017 in the canton of Bern asked if residents had taken a subsequent career choice as a GP and if so in which region. Residents scored the importance of their traineeship and their mentor's influence on becoming a GP. By using zip codes of work area of respondents already working as GPs and matching it with population census data, we could obtain the distribution of GPs on a per capita basis. Out of 165 residents who participated in a traineeship, 151 (92%) completed our survey. 81% had chosen a career as a GP or were on track to become a GP. Almost half of the participants became GPs in the offices of their mentors or in the area. Our respondents emphasized the importance of their mentors' influence as well as the training program in their decision-making to become a GP. Most mentioned benefits of being a GP were broad field of medical care (37%) and a fulfilling doctor-patient relationship (34%). We could show an increase in GP practices in the canton of Bern, not only in urban but also accordingly in rural areas. Most residents continued subsequent careers as general practitioners after having completed a GP traineeship, with almost half of them in the region of their training. A vocational training program helped motivating young doctors to become GPs and underserved regions of the canton of Bern to gain new GPs.
Multimorbidity and polypharmacy are very common in older adults in primary care. Ideally, general practitioners (GPs), should regularly review medication lists to identify inappropriate medication(s) ...and, where appropriate, deprescribe. However, it remains challenging to deprescribe given time constraints and few recommendations from guidelines. Further, patient related barriers and enablers to deprescribing have to be accounted for. The aim of this study was to identify barriers and enablers to deprescribing as reported by older adults with polypharmacy and multimorbidity.
We conducted a survey among participants aged ≥70 years, with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 chronic medications). We invited Swiss GPs, to recruit eligible patients who then completed a paper-based survey on demographics, medications and chronic conditions. We used the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire and added twelve additional Likert scale questions and two open-ended questions to assess barriers and enablers towards deprescribing, which we coded and categorized into meaningful themes.
Sixty four Swiss GPs consented to recruit 5-6 patients each and returned 300 participant responses. Participants were 79.1 years (SD 5.7), 47% female, 34% lived alone, and 86% managed their medications themselves. Sixty-seven percent of participants took 5-9 regular medicines and 24% took ≥10 medicines. The majority of participants (77%) were willing to deprescribe one or more of their medicines if their doctor said it was possible. There was no association with sex, age or the number of medicines and willingness to deprescribe. After adjustment for baseline characteristics, there was a strong positive association between willingness to deprescribe and saying that because they have a good relationship with their GP, they would feel that deprescribing was safe OR 11.3 (95% CI: 4.64-27.3) and agreeing that they would be willing to deprescribe if new studies showed an avoidable risk OR 8.0 (95% CI 3.79-16.9). From the open questions, the most mentioned barriers towards deprescribing were patients feeling well on their current medicines and being convinced that they need all their medicines.
Most older adults with polypharmacy are willing to deprescribe. GPs may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use.
Abstract
Introduction
To reduce inappropriate polypharmacy, deprescribing should be part of patients’ regular care. Yet deprescribing is difficult to implement, as shown in several studies. ...Understanding patients’ attitudes towards deprescribing at the individual and country level may reveal effective ways to involve older adults in decisions about medications and help to implement deprescribing in primary care settings. In this study we aim to investigate older adults’ perceptions and views on deprescribing in different European countries. Specific objectives are to investigate the patients’ willingness to have medications deprescribed by medication type and to have herbal or dietary supplements reduced or stopped, the role of the Patient Typology (on medication perspectives), and the impact of the patient-GP relationship in these decisions.
Methods and analysis
This cross-sectional survey study has two parts: Part A and Part B. Data collection for Part A will take place in nine countries, in which per country 10 GPs will recruit 10 older patients (≥65 years old) each (
n
= 900). Part B will be conducted in Switzerland only, in which an additional 35 GPs will recruit five patients each and respond to a questionnaire themselves, with questions about the patients’ medications, their willingness to deprescribe those, and their patient-provider relationship. For both Part A and part B, a questionnaire will be used to assess the willingness of older patients with polypharmacy to have medications deprescribed and other relevant information. For Part B, this same questionnaire will have additional questions on the use of herbal and dietary supplements.
Discussion
The international study design will allow comparisons of patient perspectives on deprescribing from different countries. We will collect information about willingness to have medications deprescribed by medication type and regarding herbal and dietary supplements, which adds important information to the literature on patients’ preferences. In addition, GPs in Switzerland will also be surveyed, allowing us to compare GPs’ and patients’ views and preferences on stopping or reducing specific medications. Our findings will help to understand patients’ attitudes towards deprescribing, contributing to improvements in the design and implementation of deprescribing interventions that are better tailored to patients’ preferences.
Investigates guideline use amongst general practitioners (GP) from 26 European countries and from Brazil, Israel and New Zealand, regarding best management of hypertension in frail oldest-old (>80 ...years of age). Examines if guideline use relates to different decisions when managing hypertension in frail oldest-old. Source: National Library of New Zealand Te Puna Matauranga o Aotearoa, licensed by the Department of Internal Affairs for re-use under the Creative Commons Attribution 3.0 New Zealand Licence.
Background: A growing shortage of general practitioners (GPs), in Switzerland and around the world, has forced countries to find new ways to attract young physicians to the specialty. In 2017, ...Switzerland began to fund hundreds of new study places for medical students. This wave of young physicians will soon finish University and be ready for postgraduate training. We hypothesized that an attractive postgraduate training program would encourage interested young physicians to pursue a GP career.
Methods: This is a cross-sectional survey of young physicians from the Swiss Young General Practitioners Association (JHaS), members of Cursus Romand de médecine de famille (CRMF), and all current medical students (5
th
or 6
th
years) (n = 554) in Switzerland, excluding students indicating definitely not to become GPs. We asked all if they were likely to become a GP (Likert: 1-10), and then asked them to score general features of a GP training curriculum, and likely effects of the curriculum on their career choice (Likert scale). They then rated our model curriculum (GO-GP) for attractiveness and effect (Likert Scales, open questions).
Results: Most participants thought they would become GPs (Likert: 8 of 10). Over 90% identified the same features as an important part of a curriculum ("yes" or "likely yes"): Our respondents thought the GO-GP curriculum was attractive (7.3 of 10). It was most attractive to those highly motivated to become GPs. After reviewing the curriculum, most respondents (58%) felt GO-GP would make them more likely to become a GP. Almost 80% of respondents thought an attractive postgraduate training program like GO-GP could motivate more young physicians to become GPs.
Conclusions: Overall, medical students and young physicians found similar features attractive in the general and GO-GP curriculum, regardless of region or gender, and thought an attractive curriculum would attract more young doctors to the GP specialty.
Key points
An attractive postgraduate training program in general practice can attract more young physicians to become GPs.
In this study cross-sectional survey including medical students (n = 242) and young physicians (n = 312) we presented general features for a curriculum and a model curriculum for general practice training, for evaluation of attractiveness to our study population.
General practice training curriculum provides flexibility in choice of rotations, access to short rotations in a wide variety of medical specialties, training in specialty practices as well, mentoring and career guidance by GPs and guidance in choosing courses/certificate programs necessary for general practice.
These findings help building attractive postgraduate training programs in general practice and fight GP shortage.
Future and practising GPs encounter various stressors, which can potentially impair mental wellbeing and develop into mental illnesses.
To assess mental wellbeing of young and future GPs by their ...level of training.
A cross-sectional anonymous survey of members of the Swiss Young General Practitioners Association (JHaS) was undertaken.
Basic characteristics and the current mental wellbeing were assessed using the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Specific stressors that can influence wellbeing were focused on. Participants were asked for ideas on how to improve wellbeing via open questions.
Response rate was 57% (
= 503). Mean value for mental wellbeing (WEMWBS) was 52.4 (maximum 70, standard deviation SD 7.2). Residents had a significantly lower level of mental health (51.0, SD 7.6) compared with GPs (54.2, SD 6.2). Overall, stress level was reported as high or very high by almost half of participants (49%). Forty-five per cent indicated a lack of private time; the highest proportion was among residents. Fifteen per cent (20% among residents) were at risk of burnout. Most frequent stressors were administrative tasks, high workload, and work demands. Support requests included improvement of work-life balance and reduction of administrative workload.
Residents had the lowest mental wellbeing, at a stress level similarly high to that of GPs. They most often indicated not having enough time for a private life and were most at risk of burnout. Improvement suggestions should be implemented to maintain mental health of young and future GPs. Particular attention should be paid to GPs in training, as owing to their reduced mental health, they may benefit most.
To study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of ...prescribing omissions in older adults with multimorbidity and polypharmacy compared with a discussion about medication in line with usual care.
Cluster randomised clinical trial.
Swiss primary care, between December 2018 and February 2021.
Eligible patients were ≥65 years of age with three or more chronic conditions and five or more long term medications.
The intervention to optimise pharmacotherapy centred around an eCDSS was conducted by general practitioners, followed by shared decision making between general practitioners and patients, and was compared with a discussion about medication in line with usual care between patients and general practitioners.
Primary outcomes were improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilisation (AOU) at 12 months. Secondary outcomes included number of medications, falls, fractures, and quality of life.
In 43 general practitioner clusters, 323 patients were recruited (median age 77 (interquartile range 73-83) years; 45% (n=146) women). Twenty one general practitioners with 160 patients were assigned to the intervention group and 22 general practitioners with 163 patients to the control group. On average, one recommendation to stop or start a medication was reported to be implemented per patient. At 12 months, the results of the intention-to-treat analysis of the improvement in appropriateness of medication (odds ratio 1.05, 95% confidence interval 0.59 to 1.87) and the number of prescribing omissions (0.90, 0.41 to 1.96) were inconclusive. The same was the case for the per protocol analysis. No clear evidence was found for a difference in safety outcomes at the 12 month follow-up, but fewer safety events were reported in the intervention group than in the control group at six and 12 months.
In this randomised trial of general practitioners and older adults, the results were inconclusive as to whether the medication review intervention centred around the use of an eCDSS led to an improvement in appropriateness of medication or a reduction in prescribing omissions at 12 months compared with a discussion about medication in line with usual care. Nevertheless, the intervention could be safely delivered without causing any harm to patients.
NCT03724539Clinicaltrials.gov NCT03724539.
Many oldest-old (> 80-years) with multimorbidity and polypharmacy are at high risk of inappropriate use of medication, but we know little about whether and how GPs would deprescribe, especially in ...the frail oldest-old. We aimed to determine whether, how, and why Swiss GPs deprescribe for this population.
GPs took an online survey that presented case-vignettes of a frail oldest-old patient with and without history of cardiovascular disease (CVD) and asked if they would deprescribe any of seven medications. We calculated percentages of GPs willing to deprescribe at least one medication in the case with CVD and compared these with the case without CVD using paired t-tests. We also included open-ended questions to capture reasons for deprescribing and asked which factors could influence their decision to deprescribe by asking for their agreement on a 5-point-Likert-scale.
Of the 282 GPs we invited, 157 (56%) responded: 73% were men; mean age was 56. In the case-vignette without CVD, 98% of GPs deprescribed at least one medication (usually cardiovascular preventive medications) stating it had no indication nor benefit. They would lower the dose or prescribe pain medication as needed to reduce side effects. Their response was much the same when the patient had a history of CVD. GPs reported they were influenced by 'risk' and 'benefit' of medications, 'quality of life', and 'life expectancy', and prioritized the patient's wishes and priorities when deprescribing.
Swiss GPs were willing to deprescribe cardiovascular preventive medication when it lacked indication but tended to retain pain medication. Developing tools for GPs to assist them in balancing the risks and benefits of medication in the context of patient values may improve deprescribing activities in practice.
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