Attitudes toward deprescribing in a middle-aged health disparities population

Does missing data matter in the revised Patients' Attitudes Towards Deprescribing questionnaire? A systematic review and two case analyses

BACKGROUND

The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire was developed to capture beliefs and perceptions of patients about deprescribing. In general, handling of missing data is underreported in survey studies. Underlying mechanisms related to missing data may impact the findings from survey studies.

OBJECTIVES

The aim of this study was to assess the missing data in studies using the rPATD questionnaire through a systematic review and datasets from two studies.

METHODS

First, this review updated a systematic review on the rPATD (and other versions). We searched Medline via OVID, EMBASE, Scopus, Web of Science until 31st January 2023. Missing data reporting and methods to handle them were collected. Second, data from two deprescribing studies were analyzed using three methods of missing data handling: complete case analysis, personal mean substitution, and multiple imputation. We compared the scores from each domain and the associations of the domains with two questions from the rPATD to highlight how using different methods can influence the interpretation of study findings.

RESULTS

We identified 49 studies: 31 (63 %) from this study and 18 (37 %) from the original systematic review. The question or domain with the most missing data could be identified in 9 studies (18.4 %). Missing data management was reported in 19 studies (38.8 %). In one case analysis, the "Burden" domain was significantly associated with the question "I would like to try stopping one of my medicines to see how I feel without it" using complete case analysis (p = 0.044) or multiple imputation (p = 0.038), but not when using personal mean substitution (p = 0.057).

CONCLUSIONS

Missing data and methods used to handle missing data were underreported in studies using the rPATD questionnaire. The methods should be chosen carefully as our analyses from two distinct studies suggest that they may impact the interpretation of the findings from the questionnaire.

Attitudes of Older Adult Patients and Caregivers Towards Deprescribing of Medications in Ethiopia

Background

Deprescribing is essential for reducing inappropriate medication use and polypharmacy. For a holistic approach, it is essential to know how older adult patients and their caregivers perceive deprescribing.

Objective

To assess the attitude of older adult patients and caregivers towards deprescribing medication at Ambo University Referral Hospital.

Methodology

Institutional-based cross-sectional study was conducted using the revised Patients' Attitude Towards Deprescribing tool (rPATD). The data was analyzed using the SPSS-25 software. Backward linear regression and logistic regression were used to measure association between outcome and determinant variables. The two-sided P-value ≤0.05 with 95% confidence interval was utilized for reporting significant factors.

Results

One hundred fifty-six (81.3%) of the respondents (ie, 85.0% of older adult and 77.2% of caregivers) agreed to stop one or more of their regular medications if the physician said it was possible despite 98 (51.0%) of them (ie, 49.0% of older adult and 53.3% of caregivers) being satisfied with their/their care recipient's medications. On the overall aggregate mean score, the respondents had a neutral position (2.6-3.59) regarding the burden and concerns of stopping medications whereas the majority of them disagree (1.0-2.59) with the inappropriateness of the medication they were taking and agreed (3.6-5.0) with the need for their involvement in treatment decision making. Concerns about stopping medicine scores (AOR = 0.440, 95% CI = 0.262-0.741, P = 0.035) and perceived levels of medication inappropriateness (AOR = 0.653, 95% CI = 0.456-0.936, P = 0.020) was significantly associated with the willingness to discontinue and overall satisfaction with their medicine regimen respectively.

Conclusion

The majority of older adult patients and caregivers would like to deprescribe if the physicians recommended it. The perceived concerns of stopping and inappropriateness of the medicines were associated with the willingness to deprescribe and overall satisfaction with their medicine respectively. Healthcare providers should prompt the deprescribing process with older adult patients and caregivers by addressing their concerns about stopping medications.

Translation, cross-cultural adaptation and validation of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire to Portuguese: Older adults version

BACKGROUND

Deprescribing is a patient-centered approach to managing inappropriate polypharmacy that faces several barriers, including patients' attitudes and beliefs about medications that need to be considered. For this purpose, the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire is a helpful instrument, but until now, there is no Portuguese version.

OBJECTIVES

To translate and validate the rPATD questionnaire (older adults version) to Portuguese.

METHODS

The rPATD questionnaire was translated and cross-culturally adapted using forward-backward translation and pre-testing. A cross-sectional study with 192 older adults aged ≥65 years taking at least 1 regular medication was conducted for validity assessment. Participants were recruited by convenience sampling in 3 Portuguese outpatient rehabilitation medicine clinics. Psychometric properties were evaluated through face and content validity; construct validity, by assessing structural validity through exploratory factor analysis, hypotheses testing, including concurrent validity and cross cultural validity; reliability with internal consistency; and item-total correlation. Floor and ceiling effects were examined.

RESULTS

The exploratory factor analysis (EFA) revealed a 4-factor structure that explains 51.08% of the total variance, as in the original rPATD. These 4 factors are related to the level of involvement in medication management, beliefs in the appropriateness of medication, perceived burden of medication, and concerns about stopping medications. Factor loadings ranged from 0.226 to 0.800; 2 items scored <0.3, and no cross-loading was found. The exclusion of the 2 items loading <0.3 in the EFA showed no significant improvement in factor loading or internal consistency, so the item structure was maintained. In hypothesis testing, 78% of the correlations were correctly predicted. The 4 factors internal consistency was generally acceptable, with Cronbach's alpha ranging from 0.638 to 0.830. The item-total correlation ranged between 0.223 and 0.7.

CONCLUSION

The Portuguese rPATD questionnaire for older adults presents globally good or acceptable psychometric properties.

Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists

Purpose:

Developing effective deprescribing interventions relies on understanding attitudes, beliefs, and communication challenges of those involved in the deprescribing decision-making process, including the patient, the primary care clinician, and the pharmacist. The objective of this study was to assess patients’ beliefs and attitudes and identify facilitators of and barriers to deprescribing.

Methods:

As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3 chronic medications. Participants were recruited from retail pharmacies associated with the University of Kentucky HealthCare system. They completed an electronic survey that included demographic information, questions about communication with their primary care clinician and pharmacists, and the revised Patients’ Attitudes Toward Deprescribing (rPATD) questionnaire.

Results:

Our analyses included 103 participants (n = 65 identified as female and n = 74 as White/Caucasian) with a mean age of 50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an average of 8.4 daily medications (SD = 6.1). Most participants reported effective communication with clinicians and pharmacists (66.9%) and expressed willingness to stop one of their medications if their clinician said it was possible (83.5%). Predictors of willingness to accept deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.45–6.2], college/graduate degree (OR = 55.25, 95% CI = 5.74–531.4), perceiving medications as less appropriate (OR = 8.99, 95% CI = 1.1–73.62), and perceived effectiveness of communication with the clinician or pharmacist (OR = 4.56, 95% CI = 0.85–24.35).

Conclusion:

Adults taking ⩾3 chronic medications expressed high willingness to accept deprescribing of medications when their doctor said it was possible. Targeted strategies to facilitate communication within the patient–primary care clinician–pharmacist triad that consider patient characteristics such as age and education level may be necessary ingredients for developing successful deprescribing interventions.

Plain Language Summary

Are patients willing to accept stopping medications?

Sometimes, medicines that a patient takes regularly become inappropriate. In other words, the risks of adverse effects might be greater than a medicine’s potential benefits. The decision to stop such medicines should involve the patient and consider their preferences. We surveyed a group of patients taking multiple medicines to see how they felt about having those medicines stopped. We also asked patients whether and how much they talk to their primary care clinician and pharmacists about their medicines. To qualify for this study, patients had to be at least 18 years old and to take three or more medicines daily; they also needed to speak English. Participants provided demographic information and answered questions about their medicines, their communication with primary care clinicians and pharmacists, and their feelings about having one or more of their medicines stopped. We recruited 107 people and were able to use responses from 103 of them. Their average age was 50 years; 65 of them identified as female, and 75 identified as White/Caucasian. Most of our participants mentioned having conversations with primary care clinicians and pharmacists and said they would be willing to stop a medication if their clinician said it was possible. Older participants, those with more years of education, those who thought their medications might lead to side effects, and those who communicated with their clinician or pharmacists were more willing to have one of their medicines stopped.

Our results indicate that patient characteristics and communication with clinicians and pharmacists are factors to consider when designing interventions to reduce the use of inappropriate medicines.

Differences in Older Patients' Attitudes Toward Deprescribing at Contextual and Individual Level

Background

Deprescribing requires patients' involvement and taking patients' attitudes toward deprescribing into account. To understand the observed variation in these attitudes, the influence of contextual-level factors, such as country or healthcare setting, should be taken into account.

Methods

We conducted a systematic review of studies using the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire among older adults. We searched articles in Medline and Embase up to 30 June 2021. PRISMA guideline was used for the search process and reporting. We summarized the outcomes from the rPATD and compared attitudes at study population level between high or low-middle-income countries, global regions, and healthcare settings using ANOVA testing. Correlations of the rPATD outcomes with the mean age of the study populations were tested. Associations with the rPATD outcomes at individual patient level extracted from the included studies were summarized.

Results

Sixteen articles were included. Percentages of patients willing to stop medication were significantly lower in low-middle-income countries (<70% in Nepal and Malaysia) compared to high-income countries (>85% in USA, Australia, European countries). No significant differences were observed when results were compared by global region or by healthcare setting but a high willingness (>95%) was seen in the two studies conducted in an inpatient population. A higher mean age at study level was associated with a higher willingness to stop medication. At individual level, associations between patient characteristics, including demographics and education, and attitudes toward deprescribing showed inconsistent results.

Conclusion

Findings about attitudes toward deprescribing are influenced by contextual factors. Future research should pay more attention to the influence of the healthcare system and setting as well as the culture on patients' attitudes.

How Willing Are Patients or Their Caregivers to Deprescribe: a Systematic Review and Meta-analysis

BACKGROUND

Polypharmacy is associated with the increased use of potentially inappropriate medications, where the risks of medicine use outweigh its benefits. Stopping medicines (deprescribing) that are no longer needed can be beneficial to reduce the risk of adverse events. We summarized the willingness of patients and their caregivers towards deprescribing.

METHODS

A systematic search was conducted in four databases from inception until April 30, 2021 as well as search of citation of included articles. Studies that reported patients' and/or their caregivers' attitude towards deprescribing quantitatively were included. All studies were independently screened, reviewed, and data extracted in duplicates. Patients and caregivers willingness to deprescribe their regular medication was pooled using random effects meta-analysis of proportions.

RESULTS

Twenty-nine unique studies involving 11,049 participants were included. All studies focused on the attitude of the patients towards deprescribing, and 7 studies included caregivers' perspective. Overall, 87.6% (95% CI: 83.3 to 91.4%) patients were willing to deprescribe their medication, based upon the doctors' suggestions. This was lower among caregivers, with only 74.8% (49.8% to 93.8%) willing to deprescribe their care recipients' medications. Patients' or caregivers' willingness to deprescribe were not influenced by study location, study population, or the number of medications they took.

DISCUSSION

Most patients and their caregivers were willing to deprescribe their medications, whenever possible and thus should be offered a trial of deprescribing. Nevertheless, as these tools have a poor predictive ability, patients and their caregivers should be engaged during the deprescribing process to ensure that the values and opinions are heard, which would ultimately improve patient safety. In terms of limitation, as not all studies may published the methods and results of measurement they used, this may impact the methodological quality and thus our findings. OPEN SCIENCE FRAMEWORK REGISTRATION: https:// osf.io/fhg94.

Attitudes and beliefs of patients and primary caregivers towards deprescribing in a tertiary health care facility

Background

Good prescribing practices form the essence of drug therapy for better patient care. The major aim of better prescribing is to improve rational prescribing. Deprescribing gained momentum in recent decades.

Objective

This study aimed to explore the attitude and beliefs of deprescribing among patients and their caregivers forming dyads in a tertiary health care facility.

Methods

Cross-sectional, questionnaire-based prospective study done for two months. Attitude towards deprescribing was assessed by using validated rPATD (revised Patient attitude towards deprescribing) questionnaire. Cohen's kappa coefficient was used to measure the agreement between the views of people and their caregivers forming dyads about medication cessation.

Results

312 patients and caregivers (156 forming dyads) participated in the study. Among 156 patients, 25.6% were hypertensives & 21.2% had diabetes. 41.7% were between 36-50 years of age. Only 16.7% belong to the elderly age group. 2.5% were taking >5 medications. 43.6% of patients and 62.2% of caregivers were female. 51.3% of the patients were willing to stop one or more of their regular medicine(s) under the treating physician's advice, but 62% were satisfied with their current medicine(s). 33.4% were reluctant to stop taking medicines for a long time.

Conclusions

In our study, more than 50% of people and their caregivers were willing to try medication cessation under their physician's recommendation. There was moderate agreement between patients and their caregivers in the trial of medication cessation. Thus, the results obtained from this study may help towards improving rationalized prescribing practices in the institutional setup.

Consumer attitudes towards deprescribing: a systematic review and meta-analysis

Background

Harmful and/or unnecessary medication use in older adults is common. This indicates deprescribing (supervised withdrawal of inappropriate medicines) is not happening as often as it should. This study aimed to synthesize the results of the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire (and revised versions).

Methods

Databases were searched from January 2013 to March 2020. Google Scholar was used for citation searching of the development and validation manuscripts to identify original research using the validated PATD, revised PATD (older adult and caregiver versions), and the version for people with cognitive impairment (rPATDcog). Two authors extracted data independently. A meta-analysis of proportions (random-effects model) was conducted with subgroup meta-analyses for setting and population. The primary outcome was the question: “If my doctor said it was possible, I would be willing to stop one or more of my medicines.” Secondary outcomes were associations between participant characteristics and primary outcome and other (r)PATD results.

Results

We included 46 articles describing 40 studies (n = 10,816 participants). The meta-analysis found the proportion of participants who agreed or strongly agreed with this statement was 84% (95% CI 81%–88%) and 80% (95% CI 74%–86%) in patients and caregivers, respectively, with significant heterogeneity (I² = 95% and 77%).

Conclusion

Consumers reported willingness to have a medication deprescribed although results should be interpreted with caution due to heterogeneity. The findings from this study moves toward understanding attitudes toward deprescribing, which could increase the discussion and uptake of deprescribing recommendations in clinical practice.

Older people's attitudes towards deprescribing cardiometabolic medication

BACKGROUND

Overtreatment with cardiometabolic medication in older patients can lead to major adverse events. Timely deprescribing of these medications is therefore essential. Self-reported willingness to stop medication is usually high among older people, still overtreatment with cardiometabolic medication is common and deprescribing is rarely initiated. An important barrier for deprescribing reported by general practitioners is the patients' unwillingness to stop the medication. More insights are needed into the influence of patients' characteristics on their attitudes towards deprescribing and differences in these attitudes between cardiometabolic medication groups.

METHODS

A survey in older people using cardiometabolic medication using the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire was performed. Participants completed the general rPATD and an adapted version for four medication groups. Linear and ordinal logistic regression were used to assess the influence of age, sex, therapeutic area and number of medications used on the patients' general attitudes towards deprescribing. Univariate analysis was used to compare differences in deprescribing attitudes towards sulfonylureas, insulins, antihypertensive medication and statins.

RESULTS

Overall, 314 out of 1143 invited participants completed the survey (median age 76 years, 54% female). Most participants (80%) were satisfied with their medication and willing to stop medications if their doctor said it was possible (88%). Age, sex and therapeutic area had no influence on the general attitudes towards deprescribing. Taking more than ten medicines was significantly associated with a higher perceived medication burden. Antihypertensive medication and insulin were considered more appropriate than statins, and insulin was considered more appropriate than sulfonylureas not favouring deprescribing.

CONCLUSIONS

The majority of older people using cardiometabolic medication are willing to stop one of their medicines if their doctor said it was possible. Health care providers should take into account that patients perceive some of their medication as more appropriate than other medication when discussing deprescribing.

Exploring Patients' Attitudes Toward Deprescribing and Their Perception of Pharmacist Involvement in a European Country: A Cross-Sectional Study

PURPOSE

To explore how adult patients perceive deprescribing in a country with developing pharmaceutical care.

PATIENTS AND METHODS

This was a multicenter cross-sectional study conducted in ten community pharmacies across Croatia. Community-dwelling adults 40 years and older, taking at least one prescription medication long term, were invited to participate. The revised and validated Patients' Attitude Towards Deprescribing Questionnaire was used to investigate community-dwelling adults' opinions on potential medication discontinuation. Questions regarding the patients' perception of pharmacist competences and involvement as well as patients' preferences in deprescribing were added. Collected data were analyzed using IBM SPSS Statistics using descriptive and inferential statistical analysis. Binary logistic regression was used to explore potential predictive factors of willingness to have medication deprescribed. All tests were performed as two-tailed and a p < 0.05 was considered statistically significant.

RESULTS

A total of 315 adults aged 40 years and older completed the questionnaire. Majority of participants, 83.81% (95% CI, 79.72% to 87.90%) stated that they were satisfied with their medications, and 83.81% (95% CI, 79.72% to 87.90%) would be willing to deprescribe one or more medications. Participants expressed a positive attitude toward pharmacists' competences (68.89%, 95% CI, 63.75% to 74.03%) and involvement in deprescribing (71.11%, 95% CI, 66.08% to 76.14%). Participants who stated specific medication as deprescribing preference were more likely show dissatisfaction with current medication and show greater willingness to have medication deprescribed. Three factors were found to be associated with a positive attitude towards deprescribing: low concerns about stopping factor score (aOR 0.54, 95% CU=0.35-0.84; p=0.006), low appropriateness factor score (aOR 0.62, 95% CI=0.39-0.98; p=0.039), and a positive opinion on pharmacist involvement (aOR 2.35, 95% CI=1.18-4.70; p= 0.016).

CONCLUSION

This study showed the patient's willingness for deprescription as well as their positive attitude towards pharmacists being involved in the process. Results favour transition to a patient-centred care and shared-decision making model.

Designing a Primary Care-Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

BACKGROUND

Patients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events.

OBJECTIVES

To elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing.

DESIGN

Qualitative approach based on semi-structured interviews with patients, caregivers, and physicians.

PARTICIPANTS

Patients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations.

APPROACH

We used constant comparison to identify and compare themes between patients, caregivers, and physicians.

KEY RESULTS

We conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers' expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations.

CONCLUSIONS

Culturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.