Exploring the Landscape of Physician Confidence
Research indicates a complex picture regarding physician confidence in deprescribing. While some studies, like one conducted in Italy, show that many general practitioners feel generally confident in their ability to deprescribe (around 72%), this confidence often decreases when specific circumstances arise. For instance, a significantly lower percentage feel comfortable deprescribing guideline-recommended therapies compared to preventive medications. The context in which the medication was initially prescribed also plays a role, with some physicians hesitant to alter a regimen started by a specialist. This suggests that while the concept is accepted in principle, its practical application is fraught with hesitation and specific challenges.
Systemic barriers impeding deprescribing
Several factors within the healthcare system create major hurdles for effective deprescribing practices. Time constraints are a frequently cited issue, with physicians often having limited time during appointments to conduct a thorough medication review and discuss the process with patients. Inadequate reimbursement for the time-intensive cognitive services involved in deprescribing also disincentivizes the process. Furthermore, the healthcare system is often fragmented, with multiple specialists prescribing medications independently, leading to a lack of coordination and a complete overview of the patient's medication list. Electronic health record systems, while intended to help, can sometimes lack user-friendly tools to support deprescribing decisions or facilitate communication between providers. The absence of comprehensive national guidelines for deprescribing, in contrast to the abundance of prescribing guidelines, further complicates the process.
Physician-centric challenges
Beyond systemic issues, physicians face personal and professional challenges that impact their willingness and ability to deprescribe. Clinical inertia, or the tendency to stick with the status quo, is a powerful force, as it is often easier to continue a medication than to navigate the risks and complexities of stopping it. There is also a fear of adverse drug withdrawal effects, which can be particularly significant with psychotropic medications like benzodiazepines. Physicians can feel vulnerable to potential accountability if a negative outcome occurs after deprescribing, leading to a cautious approach. A lack of specialized training in geriatric care and communication skills for deprescribing also contributes to low confidence. Some doctors lack sufficient knowledge about deprescribing tools and the evidence base for discontinuing certain medications, especially for patients with multiple comorbidities who are often excluded from clinical trials.
Patient and caregiver factors
Patient and caregiver perspectives significantly influence the deprescribing process. A key barrier is patient resistance to stopping medications they have taken for years, often due to a sense of security or a fear that their original symptoms will return. Many patients may not attribute their symptoms to medication side effects, mistakenly believing these issues are a normal part of aging. Communication breakdowns are also common, as patients may not feel comfortable discussing their concerns or acknowledging adherence problems. Caregivers, who often manage medications, can also hold reservations, and patient resistance is often stronger when family members are involved. Some patients may also feel that deprescribing is a signal that their doctor is giving up on them, which can impact the doctor-patient relationship and trust.
Comparing Barriers to Deprescribing
| Barrier Type | Description | Example |
|---|---|---|
| Systemic | Infrastructure and policy issues within the healthcare system. | Limited appointment time, lack of reimbursement, fragmented care across multiple specialists. |
| Physician-Specific | Clinician's personal and professional challenges and beliefs. | Fear of adverse outcomes, clinical inertia, hesitation to alter a colleague's prescription. |
| Patient/Caregiver | Concerns, beliefs, and behaviors of the patient and their family. | Fear of withdrawal symptoms, resistance to change, belief in medication effectiveness. |
Overcoming Barriers through a Multidisciplinary Approach
To overcome these pervasive barriers, a multi-pronged approach is necessary, involving healthcare systems, providers, and patients working together. Interprofessional collaboration is a crucial strategy, involving pharmacists, nurses, and other care team members in medication reviews. Pharmacists, in particular, are well-equipped to perform medication reconciliations, identify potentially inappropriate medications, and educate patients. Health systems can support these efforts by implementing electronic health record alerts to flag potential deprescribing opportunities and by improving communication channels between providers.
- Enhance Education and Training: Medical education needs to prioritize geriatric pharmacology and the principles of deprescribing for all healthcare professionals. Continuing education should focus on communication skills for sensitive conversations about medication withdrawal.
- Utilize Guidelines and Tools: Physicians can leverage established criteria like the Beers list or STOPP/START criteria to identify potentially inappropriate medications. Resources such as Deprescribing.org provide evidence-based guidelines and patient decision aids to assist in the process.
- Employ Shared Decision-Making: Engaging patients and caregivers in discussions about their medication regimen is vital. Clinicians should openly discuss the rationale for deprescribing, including potential benefits like reduced side effects and lower costs, and address fears about symptom recurrence or withdrawal.
- Prioritize Follow-up and Monitoring: The deprescribing process often requires a slow taper of one medication at a time. A clear plan for monitoring and follow-up is essential to manage potential withdrawal effects or changes in health status.
- Address Systemic Incentives: Policy changes and reimbursement models are needed to properly value the time and effort involved in medication reviews and deprescribing discussions.
Conclusion
In conclusion, while physicians may report general confidence in deprescribing, this is often conditional and tempered by a range of significant barriers. These include systemic limitations such as time constraints and fragmented care, physician-related challenges like fear of adverse events and lack of training, and patient/caregiver concerns rooted in habit and fear. Effective deprescribing for the elderly requires more than just clinician knowledge; it demands a collaborative, patient-centered approach supported by systemic changes and improved communication. By addressing these multifaceted barriers, healthcare providers can better optimize medication regimens, reduce unnecessary polypharmacy, and ultimately improve the safety and quality of life for older adults.
For more in-depth information and resources on deprescribing, visit the Canadian Deprescribing Network at Deprescribing.org.
