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J Am Geriatr Soc. 2019 Sep 11. doi: 10.1111/jgs.16157. [Epub ahead of print]

Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults.

Author information

1
Department of Medicine, Weill Cornell Medicine, New York, New York.
2
Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
3
Cardiology Division, University of Washington, Seattle, Washington.
4
Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington.
5
Department of Pharmacy, University of Washington, Seattle, Washington.
6
New England Geriatric Research, Education, and Clinical Center, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts.
7
Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
8
Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.
9
Department of Epidemiology and Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
10
Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs (VA) Medical Center, Providence, Rhode Island.
11
Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California.
12
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
13
Division of Geriatrics, San Francisca Veterans Affairs Medical Center, San Francisco, California.
14
San Francisco Veterans Affairs Medical Center, San Francisco, California.
15
Department of Medicine, University of California, San Francisco, San Francisco, California.
16
Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri.

Abstract

BACKGROUND/OBJECTIVES:

Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.

DESIGN:

National cross-sectional survey.

SETTING:

Ambulatory.

PARTICIPANTS:

Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians.

MEASUREMENTS:

Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.

RESULTS:

In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists).

CONCLUSIONS:

While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication.

KEYWORDS:

cardiovascular medications; deprescribing; polypharmacy; variation in care

PMID:
31509233
DOI:
10.1111/jgs.16157

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