Engagement of outpatient providers in a deprescribing trial for hospitalized older patients transitioning to post-acute care facilities

TL;DR

Outpatient providers agreed with most deprescribing recommendations for older patients, but were often hesitant to change medications due to lack of confidence or preference for the status quo.

Contribution

Examines actual provider responses to deprescribing recommendations during care transitions, rather than hypothetical scenarios.

Findings

Outpatient providers agreed to deprescribe 87% of the medications discussed with them.

Inertia and self-efficacy were the most common barriers to deprescribing.

Vitamins and supplements were the most frequently discussed medications for deprescribing.

Abstract

Deprescribing to reduce polypharmacy often involves conversations between patients and their providers. Prior studies have surveyed healthcare providers’ willingness to deprescribe medications for hypothetical patients and defined barriers and enablers to deprescribing from provider perspectives. Few studies, however, have examined provider barriers and enablers based on their response to actual deprescribing recommendations for patients during care transitions.

To assess providers’ response to deprescribing recommendations for patients enrolled in the Shed-MEDS clinical trial.

This was a mixed methods study within the Shed-MEDS clinical trial, which included older patients with polypharmacy transitioning from the hospital to post-acute care (PAC) for short-term rehabilitation to home. During hospitalization, a study clinician reviewed all medications taken by each patient at home and in hospital, including prescribed and over-the-counter medications. The study clinician then discussed deprescribing recommendations for medications with the patient. If the patient agreed, the study clinician contacted the outpatient prescribing provider to discuss deprescribing recommendations and assess provider agreement. Providers’ responses were categorized into barriers and enablers using a published framework: awareness, inertia, self-efficacy, feasibility, and/or tacit (no clear reason given). Responses were analyzed using descriptive statistics.

Of 186 patients randomized to the intervention, 177 completed the deprescribing discussion with the study clinician. The study clinician was successful in contacting at least one outpatient provider for 101 patients. Among 101 patients, 983 outpatient medications were recommended for deprescribing. Patients agreed to deprescribe most of these medications (72%). The study clinician was able to discuss deprescribing with outpatient providers for 315 medications, of which they agreed to deprescribe 273 (87%). Vitamins and supplements were discussed most often. Ultimately, 242 (89%) medications that providers agreed to were successfully deprescribed. The most common provider enablers to deprescribing were categorized as tacit (37%), self-efficacy (30%), and inertia (27%). However, inertia (60%) and self-efficacy (42%) also were common provider barriers.

Outpatient providers agreed with most deprescribing recommendations shared by a study clinician following patient agreement. The most common barrier to deprescribing among outpatient providers was their preference not to change medicines (inertia) and/or not feeling confident in their ability to make these changes (self-efficacy).

In a study to reduce medicines for older adults in the hospital, we found that outpatient providers agreed with most of the recommendations to reduce or stop medicines made by a study clinician. The most common barrier to reducing or stopping medicines among outpatient providers was their preference not to change medicines and/or not feeling confident in their ability to make these changes. Deprescribing interventions may be more effective for patients experiencing care transitions if these barriers are addressed with specific communication tools designed for outpatient providers.

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