Self-efficacy for deprescribing: A survey for health care professionals using evidence-based deprescribing guidelines

https://doi.org/10.1016/j.sapharm.2017.01.003Get rights and content

Highlights

  • Prescribers have identified many challenges in their ability to carry out deprescribing activities.

  • Self-efficacy reflects how long one will persevere when faced with challenges.

  • Using evidence-based deprescribing guidelines influences self-efficacy for deprescribing.

  • A self-efficacy assessment tool provides a novel approach to evaluating usefulness of polypharmacy management initiatives.

Abstract

Background

Although polypharmacy is associated with significant morbidity, deprescribing can be challenging. In particular, clinicians express difficulty with their ability to deprescribe (i.e. reduce or stop medications that are potentially inappropriate). Evidence-based deprescribing guidelines are designed to help clinicians take action on reducing or stopping medications that may be causing more harm than benefit.

Objectives

Determine if implementation of evidence-based guidelines increases self-efficacy for deprescribing proton pump inhibitor (PPI), benzodiazepine receptor agonist (BZRA) and antipsychotic (AP) drug classes.

Methods

A deprescribing self-efficacy survey was developed and administered to physicians, nurse practitioners and pharmacists at 3 long-term care (LTC) and 3 Family Health Teams in Ottawa, Canada at baseline and approximately 6 months after sequential implementation of each guideline. For each drug class, overall and domain-specific self-efficacy mean scores were calculated. The effects of implementation of each guideline on self-efficacy were tested by estimating the difference in scores using paired t-test. A linear mixed-effects model was used to investigate change over time and over practice sites.

Results

Of eligible clinicians, 25, 21, 18 and 13 completed the first, second, third and fourth survey respectively. Paired t-tests compared 14 participants for PPI and BZRA, and 9 for AP. Overall self-efficacy score increased for AP only (95% confidence intervals (CI) 0.32 to 19.79). Scores for domain 2 (develop a plan to deprescribe) increased for PPI (95% CI 0.52 to 24.12) and AP guidelines (95% CI 2.46 to 18.11); scores for domain 3 (implement the plan for deprescribing) increased for the PPI guideline (95% CI 0.55 to 14.24). Longitudinal analysis showed an increase in non-class specific scores, with a more profound effect for clinicians in LTC where guidelines were routinely used.

Conclusion

Implementation of evidence-based deprescribing guidelines appears to increase clinicians' self-efficacy in developing and implementing a deprescribing plan for specific drug classes.

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.

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      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/.

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