Characteristics of participants
Of the participants, two were female and the mean age was 54 (range 39–65); 13 practices were located in a city, 9 practices in the countryside and 7 practices in between. All participants were practising in the northern three provinces of the Netherlands.
During the process of analysing the transcripts and labelling fragments non-agreement between the two researchers did not occur. The following themes were grouped into three domains:
1. Beliefs of the GPs concerning, best practice, patients and medication
2. Knowledge and skills of the GPs
3. Guidelines for treatment and organization of healthcare
Beliefs of the GPs
In general, GPs report to support the concept of a patient-centred management as best practice. Respect for values and beliefs of the patient are a compass for their management. Discussing drug therapy with their patients, they see it as their duty to provide necessary information on possible treatment choices and their respective outcomes.
Above all you should provide sufficient information to enable people to make a choice. Honest and good information.
Let people choose for themselves however. Not based on emotions but numbers. Explain it with percentages.
In practice, however, they experience a number of problems with actually addressing the issue of deprescribing medication. Based on their experience, they consider that their patients have no problem with polypharmacy, or with medication burden,
The discontent rarely lies with old people themselves.
but on the other hand they are aware of the importance to know how a patient values his medication
I think that it’s important how people themselves look onto their medication.
Some GPs indicate that patients appear to cling to their extensive medicationlist.
..some patients love all those drug, to show off to their neighbours.’ You know what mass I have to take each day?’
Nonetheless, the GPs acknowledge that they may not be fully aware of the actual problems patients experience. In the GPs’ view, patients underreport possible ADEs, attributing these symptoms to old age rather than to their medication.
They accept these symptoms, they are part of their aging.
In addition, patients may report their symptoms to other healthcare professionals, for example, to the medical specialist, nurse practitioners or specialist nurses. Moreover, GPs are reluctant to initiate a discussion about stopping medication because they are concerned that patients may interpret this as a sign of being given up on.
People may then get the feeling, ‘Don’t I count anymore, am I not important?’
The GPs hesitate to discuss the subject of life expectancy with their patients.
I think it’s tricky to discuss life expectancy with a patient.
On the other hand some participants report how patients spontaneously talk about their limited life expectancy.
‘What ‘s left for me, is limited.’
‘Well doc, when it’s over tomorrow, that’s OK with me’.
Some GPs think that confronting a patient with a discussion about life expectancy versus quality of life is not ethical. At the same time, however, others report that a discussion with their patient about the quality of the patient’s remaining lifetime had a positive effect on their relationship.
Participants vary in their belief on the effects of preventive drug therapy in elderly patients. Some state that the benefit of preventive medication for the individual patient is small, but at a population level worthwile.
I think these (ARR) numbers are low; these numbers are disappointing.
Finally, some GPs mention patient characteristics as a barrier to the patient’s understanding of the issue.
Low education and old age means it is more difficult to discuss these matters.
Knowledge and skills
Confronted with multimorbidity and its ensuing problems GPs experience difficulties in identifying ADEs, and take the patient’s judgement in this matter seriously.
Which drugs do you think are responsible? Patients are mostly right.
During the meetings it became clear that there is an obvious difference for GPs between stopping medication on account of symptoms and intervening in long-term preventive medication. Participants felt competent in symptom management, stopping medication when symptoms are cured or relieved. For chronic problems, the symptomatic medication was tailored to an optimum as indicated by the patient’s feedback. Preventive medication, however, did not offer such a compass. The real area of concern for the participants was how to manage the long-term use of preventive medication.
In my view there’s a big difference between drugs meant for prevention and the drugs that are really therapeutic.
I focus first on preventive medication: which drug is really indicated?
The problem of the lack of evidence of the effects of preventive medication in the very elderly is paramount
With a 40
year old, I’m fairly confident deciding on what medication to prescribe. But I notice I’m less certain with an 80
I take her quality of life into account and ask myself will she live long enough to benefit from this (preventive) drug?
GPs indicate a strong need for clear information on the benefit/risk ratio of preventive medication in the very old and often frail.
Giving the patient real choices, providing information is very useful. For instance, by putting ARR numbers on the package.
Even if such information were available, some participants feel incompetent in risk communication, and others consider this information not helpful for actual shared decision-making.
We can’t predict the effect for the individual patient.
The coloured numbers in the cardiovascular risk tables of our guideline have an important effect: when your patient sees himself land in orange or red his motivation is influenced.
All participants admit they were seldom aware of their patients’ treatment preferences.
Where some participants express problems with explaining the tension between quality and length of life,
An elderly person stands up, feels dizzy as hell, but he may live a little longer. Well, these matters I discuss.
others emphasize the option of taking a positive approach to stopping preventive medication.
You can have a field day with crossing off medication: ‘sure, scrap half of it’.
Guidelines and organization of healthcare
Another important group of barriers concerns the current guidelines. GPs feel forced by current guidelines to prescribe many different medicines: they appear to pile the recommendations of one guideline on another instead of prioritizing.
To me, the guidelines are kind of a hindrance. At the moment they do not cater for older patients.
Participants claim they often feel guilty when their adherence to guidelines is not up to scratch.
I have difficulty not following the guidelines if I don’t have good reasons to do so.
A new patient entering the practice list is welcomed as an opportunity to review their medication. Some GPs complain about an inadequate overview of the patient’s medication.
The problem is that the medication lists of the doctors involved are not exchanged and are consequently inconsistent.
In multimorbidity, several healthcare providers are involved in a patient’s treatment and communication is sometimes poor. Cooperation with prescribing medical specialists who represent ‘their’ guideline is the next important barrier to deprescribing medication.
All doctors should speak with one voice. Different stories provoke distrust.
In addition, most GPs work closely with a local pharmacist: the task perception of such pharmacists was an important factor when a GP was looking for decision support in medication review.