Physicians', Nurses' and Pharmacists' Perceptions of Determinants to Deprescribing in Nursing Homes Considering Three Levels of Action: A Qualitative Study.

Rose-Anna Foley,Daria Koutaissoff,Lucie Lechevalier Hurard,Olivier Bugnon,Anne Niquille,Damien Cateau

doi:10.3390/pharmacy8010017

Abstract

Background: Polypharmacy and the use of potentially inappropriate medications are frequent safety issues among nursing home (NH) residents. Deprescribing can significantly reduce the number of drugs used, medication costs, and mortality. This qualitative study sought to understand and compare the perceptions and practices of nurses, pharmacists, and physicians regarding deprescribing in Swiss NHs, referring to an implementation approach on three levels of action: the individual, the institution, and the healthcare system. Methods: Two focus groups were held with 21 participants: one focus group with 11 pharmacists, another with 10 nurses and six semi-structured interviews with physicians were conducted and focused on their individual experience and practices. They were audiotaped and fully transcribed, and a content analysis was performed using to MAXQDA (Ver 12) software. Results: (1) At an individual level, physicians were concerned by consequences of deprescribing in terms of safety. Nurses were closest to residents and stressed the importance of finding the right time, creating a bond of trust before deprescribing and considering the purpose of the stay in the NH. Pharmacists relied on structured guides for deprescribing, which led their reflection and practice. All professionals saw the complexity of the clinical situations, as well as residents’ and relatives’ fears of interruption of care. (2) At an institutional level, the professionals stressed the lack of time to discuss patients’ health and treatment, while pre-existing interprofessional collaboration, specifically, quality circles, seemed useful tools to create common knowledge. In order to reduce prescriptions, better coordination between physicians, nurses, pharmacists and specialists seemed crucial. (3) At the health system level, funding still needs to be provided to consolidate the process, go beyond organisational constraints and ensure deprescribing serves the patient’s wellbeing above all. Conclusions: At the individual level of implementation, the different healthcare professionals expressed specific concerns about deprescribing, depending on their defined role in NHs. Their perspective about the different levers to promote deprescribing at institutional and healthcare system levels converge towards interprofessional collaboration supported by the healthcare system. Specific funding and incentives are therefore needed to support a sustainable interprofessional team.

Highlights

Polypharmacy, commonly defined as the use of five or more concomitant drugs, and the use of potentially inappropriate medications (PIMs) are frequent problems among nursing home (NH)residents
Since this study aimed at informing a further intervention in NHs, we referred to an “applied” implementation science approach, considering that the determinants of implementation stand on multiple organisational levels, from the individual to the healthcare system as a whole [19], enabling to find effective levers to support the use of deprescribing in NHs, with a complex and critical view on the matter
Analysis: The analysis focused on the differences between three professional statuses: pharmacists (Pha), physicians (Phy) and nurses (N)

Summary

Introduction

While polypharmacy is sometimes necessary to treat severe illness, and the use of a potentially inappropriate drug can be the best choice available for a specific patient, both are independently associated with worse health outcomes, lower quality of life, and increased risk of hospitalisation and death [1,6,7,8,9] In this context, deprescribing, defined as “the process of withdrawal of an inappropriate medication, supervised by a healthcare professional with the goal of managing polypharmacy and improving outcomes” [10], seems a useful approach. In Switzerland, no major initiatives to promote deprescribing in NHs have been launched so far, either by health authorities or by professional societies An explanation for this could be that, especially in NHs, deprescribing remains a complex matter, involving the active participation of residents, families, physicians, nurses and pharmacists, each group with its own goals and set of priorities [14].

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