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Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study.

ABSTRACT: OBJECTIVES:To explore general practitioners' (GPs) routines and considerations on (de)prescribing antihypertensive medication (AHM) in older patients, their judgement on usability of the current guideline and needs for future support. DESIGN:Semistructured interviews. SETTING:Dutch general practice. PARTICIPANTS:Fifteen GPs were purposively sampled based on level of experience and practice characteristics until saturation was reached. RESULTS:GPs appeared reluctant to start AHM, especially in patient >80 years. High systolic blood pressure and history of cardiovascular disease or diabetes were enablers to start or intensify treatment. Reasons to refrain from this were frailty and patient preference. GPs described a tendency to continue AHM regimens unchanged, influenced by daily time constraints, automated prescription routines and anticipating discomfort when disturbing patients' delicate balance. GPs were only inclined to deprescribe AHM in terminally ill patients or after prolonged achievement of target levels in combination with side effects or patient preference. Deprescription was facilitated when GPs had experience with patients showing increased quality of life after deprescription and was withheld by anticipated regret (ie, GPs' fear of a stroke after deprescribing). GPs felt insufficient guidance from current guidelines, especially on deprescription. CONCLUSIONS:GPs are reluctant to start or deprescribe AHM in older people and have a propensity to continue AHM within a daily routine that insufficiently supports critical medication review. (De)prescription is influenced by patient preferences and anticipated regret and current guidelines provide insufficient guidance.

SUBMITTER: van Middelaar T

PROVIDER: S-EPMC5914897 | biostudies-other | 2018 Apr

REPOSITORIES: biostudies-other

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Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study.

van Middelaar Tessa T Ivens Sophie D SD van Peet Petra G PG Poortvliet Rosalinde K E RKE Richard Edo E Pols A Jeannette AJ Moll van Charante Eric P EP

BMJ open 20180420 4

<h4>Objectives</h4>To explore general practitioners' (GPs) routines and considerations on (de)prescribing antihypertensive medication (AHM) in older patients, their judgement on usability of the current guideline and needs for future support.<h4>Design</h4>Semistructured interviews.<h4>Setting</h4>Dutch general practice.<h4>Participants</h4>Fifteen GPs were purposively sampled based on level of experience and practice characteristics until saturation was reached.<h4>Results</h4>GPs appeared relu ...[more]

PMID: 29678989

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Project description:More and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people.In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n?=?9), NPs (n?=?10), PAs (n?=?5) and RNs (n?=?10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction.In most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs.The roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.

Project description:ObjectivesTo explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention.Design, setting and participantsSemi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis.ResultsTwenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication.ConclusionsResults demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.

Project description:BackgroundA cloud-based mobile electronic prescribing and medication management system (ePMMS), in which prescribers' orders directly populate residential aged care facility (RACF) medication administration records (MARs) and are communicated electronically to the RACF's pharmacy, may create efficiencies and improve patient safety when compared to the paper-based and hybrid paper-electronic medication management systems used in most Australian RACFs. Little is known about general-practitioners' (GPs'), nurses' and pharmacists' acceptance of, or experiences with, ePMMS.ObjectivesTo explore the uptake of an ePMMS by GPs, and the experiences and perceptions of GPs, nurses and pharmacists, at a 90-bed RACF that tested a beta-version ePMMS.MethodsRetrospective audit to determine the proportion of medicines ordered by GPs via the ePMMS over a three-month period. Focus groups conducted three-to-four months after implementation: one with GPs (n=5), one with nurses (n=12); in-depth interview/survey of pharmacists (n=2). Qualitative data were analysed thematically.ResultsThree of seven GPs used the ePMMS to order medicines; 53/205(25.9%) medicines were ordered via the ePMMS by GPs. Two broad themes were identified: benefits of the ePMMS, and barriers/limitations. Benefits related to patient safety and workforce efficiency, and included GPs' ability to access and modify residents' MARs remotely, no need for nurses to fax orders to the pharmacy, and no need for pharmacy transcription of GPs' handwritten orders to create electronic MARs. Barriers and limitations related to inefficiency, low GP uptake and training/support, and included slower prescribing compared to written orders, the need for GP-signed paper copies of the MAR, lack of integration with GP clinic software, and low GP motivation to use the system, especially GPs with few patients at the RACF.ConclusionsGPs, nurses and pharmacists felt the ePMMS improved medication-safety and workforce-efficiency, however a number of barriers were identified that contributed to low GP-uptake and limited the benefits.

Dataset Information

Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study.

Publications

Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study.

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