Key Takeaways
1. Rating Level of Disagreement: Enrolled participants received 1 of 2 possible vignettes and rated their agreement on a scale from 1 to 6, with 1 being “strongly disagree” and 6 meaning “strongly agree.” Participants who responded with a score of 1 to 3 were included in the study.
2. Factors Influencing Disagreement: The study identifies various factors that contributed to participants’ disagreement with deprescribing recommendations, including doubts about deprescribing, valuing medications, fear of complications, and the need for additional communication and information prior to deprescribing.
3. Different Views in Deprescribing: Compared to participants who strongly disagreed with deprescribing recommendations, participants who disagreed were more likely to be interested in additional communication, alternative strategies, or consideration of medication preferences.
The discontinuation of medications through deprescribing is a safe approach when the benefits are outweighed by the drawbacks and consideration is given to the patient’s circumstances, level of function, and preferences; however, deprescribing medication in clinical practice can be difficult due to older adults not always being receptive to stopping medication. Patients’ hesitancy and confusion when instructed by physicians to stop taking a medication is believed to be a result of the physician’s initial emphasis on adherence when prescribing a medication.
Using hypothetical scenarios, authors of a study published in JAMA Network Open examine the factors that older adult participants stated were important and contributed to their disagreement with physicians’ deprescribing recommendations. The online study’s primary outcome was the attitudes, beliefs, fears, and recommended actions of participants in response to their physicians’ recommendation of deprescribing. Investigators analyzed the reasons provided by participants who disagree with deprescribing. To decrease selection bias, the participants were not informed of the survey topic upon enrollment.
Participants were provided with 1 of 2 possible vignettes describing a woman 76 years of age who takes 11 medications to manage her health conditions and is recommended to stop taking either simvastatin (Zocor; Merck & Co.), to prevent heart disease and stroke, or lansoprazole (Prevacid; Takeda), to treat indigestion. The rationales provided for stopping a medication were either a lack of benefit, potential for harm, or both. Participants were to rate their agreement using a 6-point scale, with 1 meaning “strongly disagree” and 6 meaning “strongly agree”. Those who answered with a score of 4 or higher were excluded from the study.
A total 899 participants aged 65 years and older who had doubts about deprescribing were included in the analysis. Participants were asked to report the number of medications they take, their personal experience with the therapeutic class of medication presented in the vignette at enrollment, and the amount of support they need to manage their medications. Further, participants were asked to self-report their general health and health literacy.
Of the 899 enrolled participants, 558 (62.1%) had heard the simvastatin vignette and the remaining 341 (37.9%) participants had heard the lansoprazole vignette. Further, 494 participants (54.9%) had at least 1 code in the attitudes, beliefs, and fears category, whereas 413 participants (45.9%) had at least 1 code in the proposed strategies category. The attitudes, beliefs, and fears expressed by participants were doubts about deprescribing (361 participants [40.2%]), values medications (139 participants [15.5%]) and avoiding change (132 [14.7%]), and suggested strategies to increase agreement with deprescribing included improving communication (225 participants [25.0%]), alternative strategies (138 [15.4%]), and consideration of medication drug preferences (137 [15.2%]).
Compared to those who received the lansoprazole vignette, the participants who received the simvastatin vignette were less likely to report doubts about deprescribing (153 [44.9%] versus 208 [37.3%], respectively; P = .02) and were less likely to report the theme of questioning whether or not the medication is causing problems (70 [20.5%] versus 75 [13.4%], respectively; P = .01). In addition, this group was less likely to report the domain of avoiding change (54 [9.7%] vs 78 [22.9%], respectively; P < .001), including the themes of maintaining the status quo (36 [6.5%] vs 48 [14.1%], respectively; P < .001) or long-term use of the medication (22 [3.9%] vs 40 [11.7%], respectively; P < .001).
Those who received the simvastatin vignette were more likely to report the domain of communication which included the theme that further information is necessary prior to deprescribing (simvastatin: 160 [28.7%]; lansoprazole: 65 [19.1%]). Although there was no difference in rates of the domain of medication preferences, participants who received the simvastatin vignette were less likely to be interested in tapering or reducing medication (simvastatin: 22 [3.9%]; lansoprazole: 31 [9.1%]).
Participants who received the potential for harm rationale (145 [45.2%]) were most likely to report the domain of doubts about deprescribing medication compared to those who received rationales about the lack of benefit (113 [35.3%]) and the combination of both rationales (103 [39.9%]; P = .04). Further, participants who received the potential for harm rationale were more likely to question whether the medication caused problems (73 [22.7%]) compared with the lack of benefit (33 [10.3%]) or both (39 [15.1%]; P < .001).
In addition, participants with personal medication experience were more likely to report the domain of valuing medications than those without personal experience (93 of 517 [18.0%] versus 46 of 318 [12.1%]; P = .02). There was little difference in the overall domain of doubts about deprescribing by personal medication experience (155 [40.7%]) and no personal experience (206 [39.9%]); however, those with personal medication experience were more likely to report fear of worsening symptoms or health (113 [21.9%]), and were less likely to report questioning if the medication was the cause of complications (69 [16.2%]) or concern about the medication being stopped (41 [7.9%] vs 48 [12.6%]).
Participants who strongly disagreed with the recommendation were more likely to report valuing medications and finding them important or necessary compared to those who disagreed (48 of 205 [23.4%] vs 91 of 694 [13.1%]); however, there were no differences in the rates of reporting doubts about deprescribing by level of disagreement (strongly disagree, 74 [36.1%]; disagree, 287 [41.4%]; P = .18). Further, those who strongly disagreed with the recommendation were less likely to report needing additional communication and information prior to deprescribing than those who disagreed (29 [14.2%] vs 196 [28.2%], respectively). In addition, compared to those who disagreed, participants who strongly disagreed were less likely to report medication preferences (15 [7.3%] vs 122 [17.6%], respectively; P < .001) and the associated theme of tapering or reducing medication (5 [2.4%] vs 48 [6.9%], respectively; P = .02).
A limitation of the study includes the lack of information on the participants’ medical conditions that could influence their responses. Further, the survey had used hypothetical vignettes that may not accurately reflect the decisions that participants would make in real life. The authors suggest that the findings can help identifying the degree of disagreement with deprescribing, and can be utilized to tailor patient-centered communication about deprescribing medication in older adults.
Reference
Weir KR, Shang J, Choi J, Rana R, Vordenberg SE. Factors Important to Older Adults Who Disagree With a Deprescribing Recommendation. JAMA Netw Open. 2023;6(10):e2337281. doi:10.1001/jamanetworkopen.2023.37281
