An exploration of deprescribing barriers and facilitators for older patients in primary care in Ireland – the potential role of the pharmacist

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Hansen, Christina Raae
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University College Cork
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Introduction: The older population, often defined as people aged ≥ 65 years is growing. With older age, the risk of multimorbidity (commonly defined as the presence of ≥ 2 chronic conditions) increases together with the use of a high number of daily medicines or polypharmacy (≥ 5 daily medicines). These are two risk factors of poor health outcomes in older people, putting them at greater risk of experiencing potentially inappropriate prescribing (PIP), adverse drug events (ADEs) and poor quality of life (QoL). To reduce polypharmacy and the associated risk, the number of medications used per patient needs to be reduced by means of carefully considered deprescribing when appropriate. Deprescribing is the process of discontinuing inappropriate medications with the goal of optimising pharmacotherapy and improving health outcomes. Existing research is limited to support the effective and practical implementation of deprescribing. Pharmacists are trained to evaluate PIP and their knowledge and skills may benefit the process of deprescribing. As the majority of prescribing takes place in primary care, it is logical that GPs would liaise with community pharmacists in a collaborative intervention/practice to deprescribe. Therefore, the aim of this thesis was to identify the challenges and potential benefits of deprescribing, and to explore the potential involvement of the community pharmacist in deprescribing. Methods: A study design comprising both quantitative and qualitative designs was used. Firstly, a narrative literature review summarised the existing qualitative and quantitative literature on healthcare professionals’ views on deprescribing (Chapter 2). Secondly, a systematic literature review and meta-analysis was conducted according to the PRISMA guidelines, to determine the effectiveness of existing deprescribing interventions (Chapter 3). Thirdly, to determine if PIP is predominantly a phenomenon of later life or whether it has its origins in early old age, a secondary data analysis of a population-based primary care cohort of patients aged 60-74 years was done over a continuous five-year period (Chapter 4). Fourthly, total net ingredient cost (NIC) was estimated for the PIMs identified in the same population-based primary care cohort studied in Chapter 4 in the period from 2016 to 2018, and a potential cost reduction of the routine application of the STOPP criteria was determined (Chapter 5). Fifthly, the views of community pharmacists on their role in medication optimisation and reducing PIP was examined in a qualitative interview study (Chapter 6). Finally, the views of general practitioners (GPs) and community pharmacists, on their collaboration and the potential role of the pharmacist in deprescribing, were explored in a qualitative study (Chapter 7). Results: The narrative review (Chapter 2) included 23 studies. The content analysis identified five broad themes describing the barriers and facilitators of deprescribing in older patients with multimorbidity: (i) interprofessional relationships, (ii) medication review, (iii) information, (iv) the patient and (v) environmental needs. The systematic literature review (Chapter 3) summarised findings of 31 studies of which 30 studies were included in the behaviour change component (BCT) analysis and 21 were included in the meta-analysis. The meta-analysis showed that deprescribing interventions are effective in reducing the number of drugs and inappropriate prescribing in older people, although the evidence is mixed. BCT clusters more frequently present in studies reporting intervention effectiveness compared to studies reporting no effectiveness were: goals and planning; shaping knowledge; natural consequences; comparison of behaviour; comparison of outcomes; regulation; antecedents; and identity. A total of 974 participants aged 60-74 years were included in the secondary analysis in Chapter 4 and data from baseline to year 5 of follow-up was studied. The odds of being exposed to potential prescribing omissions (PPOs) and potentially inappropriate medications (PIMs) increased significantly during years of follow-up (OR 1.08, 95% CI 1.07 1.09 and OR 1.04 95% CI 1.03, 1.06, respectively). A higher number of medicines and new diagnoses were associated with the increasing trend in both PPO and PIM prevalence. The cost-analysis in Chapter 5 was based on the same population studied in Chapter 4 (n=974) but in the period from 2016 to 2018 (year 6 to year 8 of follow-up). The study showed a high prevalence of PIMs (46%-52%) during the study period. The total net ingredient cost of PIMs identified ranged from €87,152.04 at year 6 and €86,112.48 at year 8 of follow-up. The mean cost of PIM per participant per year was between €178.68 - €179.64 during the three years of follow-up. The qualitative interviews (Chapter 6) included a total 18 community pharmacists. Seven domains from theoretical domains framework (TDF) were identified as relevant to PIP reduction and pharmacist involvement: (i) beliefs about capabilities, (ii) environmental context and resources, (iii) knowledge, (iv) social influences, (v) social professional role and identity, (vi) memory, attention and decision processes, and (vii) reinforcement. In Chapter 7, a total of 26 interviews were conducted with GPs and community pharmacists. The thematic content analysis identified five themes relevant to the role of the community pharmacist in deprescribing: (i) the GP’s role in deprescribing – is there room for a pharmacist?, (ii) working relationship, (iii) the role of the pharmacist in deprescribing, (iv) patients’ interaction with the healthcare system, and (v) environmental factors. Conclusions: The findings presented in this thesis provide a detailed understanding of the potential role of the community pharmacist in deprescribing. The prospective benefits of and the barriers and facilitators to pharmacists involved in this role of deprescribing have also been elucidated. This thesis contributes to the existing literature, through the provision of novel research that demonstrates the need for the community pharmacist support within the context of deprescribing. The community pharmacist is in a favourable position to bring pharmaceutical care closer to the patient through patient counselling and close collaboration with the patient’s GP. To integrate the role of the pharmacist with that of the GP in practice, there is a need to consider the mode of pharmaceutical service delivery and to expand the collaboration between community pharmacists and GPs by building on existing positive experiences of collaboration and clearly define the role and responsibilities of the community pharmacist in deprescribing.
Deprescribing , Pharmacist , Potentially inappropriate prescribing , Primary care , Older people
Hansen, C. R. 2019. An exploration of deprescribing barriers and facilitators for older patients in primary care in Ireland – the potential role of the pharmacist. PhD Thesis, University College Cork.