General practitioners' deprescribing decisions in older adults with polypharmacy: a case vignette study in 31 countries.

BACKGROUND General practitioners (GPs) should regularly review patients' medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients' health. However, deprescribing can be challenging for physicians. This study investigates GPs' deprescribing decisions in 31 countries. METHODS In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs' deprescribing decisions. RESULTS Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57). INTERPRETATION The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD

An international case-vignette study to assess general practitioners’ willingness to deprescribe (LESS)

Background: Globally, many oldest-old (>80 years of age) suffer from several chronic conditions and take multiple medications. Ideally, their general practitioners (GPs) regularly and systematically search for inappropriate medications and, if necessary, deprescribe those. However, deprescribing is challenging due to numerous barriers not only within patients, but also within GPs. Research questions: How does the willingness to deprescribe in oldest-old with polypharmacy differ in GPs from different countries? What factors do GPs in different contexts perceive as important for deprescribing? Method: We assess GPs' willingness to deprescribe and the factors GPs perceive to influence their deprescribing decisions in a cross-sectional survey using case-vignettes of oldest-old patients with polypharmacy. We approach GPs in 28 European countries as well as in Israel, Brazil and New Zealand through national coordinators, who administer the survey in their GP network. The case vignettes differ in how dependent patients are and whether or not they have a history of cardiovascular disease (CVD). For each case vignette, GPs are asked if and which medication they would deprescribe. GPs further rate to what extent pre-defined factors influence their deprescribe decisions. We will compare the willingness to deprescribe and the factors influencing deprescribing across countries. Multilevel models will be used to analyze the proportions of the deprescribed medications per case along the continuum of dependency and history of CVD and to analyze the factors perceived as influencing deprescribing decisions. Results: As of early-July 2018, the survey has been distributed in 14 countries and >650 responses have been returned. We will present first results at the conference. Conclusions: First, assessing GPs’ willingness to deprescribe and comparing the factors influencing GPs’ deprescribing decisions across countries will allow an understanding of the expected variation in the willingness to deprescribe across different contexts. Second, it will enable the tailoring of specific interventions that might facilitate deprescribing in oldest-old patients. Points for discussion: How can we explain differences across countries? How can the results be translated into practice in order to help GPs to optimize deprescribing practices? What factors could help GPs to implement deprescribing in oldest-old patients with polypharmacy