Self-efficacy for deprescribing: A survey for health care professionals using evidence-based deprescribing guidelines☆
Introduction
Polypharmacy is a global problem.1, 2, 3, 4 It involves the use of more medications than needed, or that could cause more harm than benefit. Polypharmacy is particularly problematic in the elderly and has been associated with falls, cognitive impairment, non-adherence, emergency room visits, hospitalizations and even mortality.5, 6, 7, 8, 9, 10 Despite these concerns, clinicians and patients often find it difficult to reduce or stop medications.11, 12 Guidance about how to balance benefit and risk of continuing or stopping medication, and about the steps for dose reduction and monitoring effect, would be extremely helpful for clinicians and patients alike.13
Evidence-based deprescribing guidelines could help clinicians and patients to make these decisions. Deprescribing is the planned and supervised process of dose reduction or stopping of medication that may be causing harm or may no longer be providing benefit. The deprescribing guidelines discussed in this study addressed proton pump inhibitors (PPI),14 benzodiazepine receptor agonists (BZRA)15 and antipsychotics (AP).16 Each of the 3 guidelines were piloted in 6 practice sites in Ottawa, Canada and their use evaluated using developmental evaluation.17
While deprescribing has been shown to be feasible and safe when monitored,18 many clinicians express discomfort with their ability to deprescribe for a number of reasons (e.g., concern about withdrawal reactions, stopping something prescribed by someone else, lack of clarity regarding tapering and monitoring approaches).11
Self-efficacy may play a significant role in a clinician's willingness and ability to deprescribe. Self-efficacy is the belief that one is capable of organizing and completing actions to achieve specific results and reflects how long one will persevere when faced with challenges.19, 20 This construct is thought to be important in the deprescribing process because clinicians acknowledge the need for deprescribing but identify a wide range of impediments.11 Since people are able to alter their behaviour through their perceived self-efficacy,19 this study examined whether self-efficacy for deprescribing tasks could be affected by the use of our deprescribing guidelines.
This paper describes the development and use of a survey to measure self-efficacy for deprescribing tasks. The main objective was to determine whether the use of deprescribing guidelines would change the perception of self-efficacy and also whether such changes might differ depending on practitioner type, practice site or specific guideline.
Section snippets
Overview
A deprescribing self-efficacy survey was developed and administered to clinicians before, and 4–6 months after, the sequential implementation of each of 3 deprescribing guidelines in 6 practice sites. Detailed methods for the developmental evaluation of the deprescribing guideline development and implementation are found in the paper by Conklin et al.17
Instrument development
A literature review was conducted to identify steps in the prescribing and deprescribing processes that were relevant to carrying out the act of
Results
Eighty-seven data records from participants who completed at least one round of survey were obtained from online responses. Five responses without valid identification, 6 duplicated responses, 17 with incomplete responses and 9 responses from people who were not a physician, pharmacist or nurse-practitioner were excluded. Valid responses from 50 participants were included in the analysis. These 50 participants provided 79 responses across the 4 survey rounds. Surveys were completed by 25 of
Discussion
When designing this study, it was known that many barriers to deprescribing had been identified.11 It was speculated that some clinicians are reluctant to deprescribe because of low self-efficacy in the light of such impediments, which led to the investigation of whether using evidence-based deprescribing guidelines would increase self-efficacy.
To place the findings of this study in the context of the full deprescribing guideline project experience, in other interviews it was learned from users
Conclusion
The implementation of evidence-based deprescribing guidelines appeared to increase clinician perceived self-efficacy in both developing and implementing a deprescribing plan for specific drug classes. If this is correct, then evidence-based deprescribing guidelines could be a useful component in the effort to address the global problem of polypharmacy. More research is needed to determine whether these increases in self-efficacy lead consistently to positive and sustainable changes in behaviour
Funding
The “Deprescribing Guidelines in the Elderly Project” is a research program of The Ontario Pharmacy Research Collaboration (OPEN) which is funded by the Government of Ontario. BF and JC received the funding. The views expressed in this article are those of the authors and do not represent those of the Government of Ontario. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Grant #06674 //www.health.gov.on.ca/en/pro/ministry/research/hsrf.aspx
Conflict of interests
BF received research funding to develop and evaluate implementation of deprescribing guidelines and has received financial payments from Institute for Healthcare Improvement and Commonwealth Fund for deprescribing guidelines summary and from Ontario Long-Term Care Physicians Association, Ontario Pharmacists Association, and Canadian Society of Hospital Pharmacists for lectures. LR-W is a coinvestigator in a research group, led by BF and JC that received research funding to develop and implement
Acknowledgements
Carlos Rojas-Fernandez, PharmD, Kevin Pottie, MD, Wade Thompson, BScPhm, Anne Monahan, MD, Pamela Eisener-Parsche, MD and Salima Shamji, MD, provided clinical input for survey design. Dee Mangin, MD and Danijela Gnjidic PhD, MPH were among the 3 who provided input to assess face validity. Hannah Irving, MA, Lisa Pizzola, MSc, and Katherine Smith, MSc, liaised with the implementation sites and distributed the surveys.
References (51)
- et al.
Polypharmacy in elderly patients
Am J Geriatr Pharmacother
(2007) - et al.
Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes
Clin Geriatr Med
(2012) - et al.
Quality criteria were proposed for measurement properties of health status questionnaires
J Clin Epidemiol
(2007) - et al.
A scale to measure pharmacy students' self-efficacy in performing medication therapy management services
Am J Pharm Educ
(2013) - et al.
The use of research in local health service agencies
Soc Sci Med
(1999) - et al.
Trends in prescription drug use among adults in the United States from 1999-2012
JAMA
(2015) - et al.
The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995-2010
BMC Med
(2015) Drug Use Among Seniors on Public Drug Programs in Canada, 2012
(2014)- et al.
Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992-2002
Int J Clin Pharmacol Ther
(2007) - et al.
Polypharmacy and falls in the middle age and elderly population
Br J Clin Pharmacol
(2006)
Medication-related falls in the elderly: causative factors and preventive strategies
Drugs Aging
Polypharmacy status as an indicator of mortality in an elderly population
Drugs Aging
The impact of polypharmacy on the health of Canadian seniors
Fam Pract
Emergency hospitalizations for adverse drug events in older Americans
N Engl J Med
Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis
BMJ Open
Patient barriers to and enablers of deprescribing: a systematic review
Drugs Aging
What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process
PLoS One
Developmental evaluation as a strategy to enhance the uptake and use of deprescribing guidelines: protocol for a multiple case study
Implement Sci
Medication withdrawal trials in people aged 65 years and older: a systematic review
Drugs Aging
Self-efficacy: The Exercise of Control
Guide for constructing self-efficacy scales
Minimizing inappropriate medications in older populations: a 10-step conceptual framework
Am J Med
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2022, Research in Social and Administrative PharmacyCitation Excerpt :In Australia, a study of hospital clinicians and medical students found similar results of limited baseline self-efficacy for deprescribing, which was improved after completion of an e-learning module on polypharmacy and deprescribing.66 Additionally, evidence-based deprescribing guidelines have also been shown to increase self-efficacy of healthcare providers.67 Most patients wish to be involved in decision making regarding their own medications.68
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For more information about deprescribing guidelines research and access to the full deprescribing self-efficacy survey, see http://deprescribing.org/resources/deprescribing-algorithms/.