Ailabouni N J, Nishtala P S, Mangin D, Tordoff J M
School of Pharmacy, University of Otago, Dunedin, New Zealand.
University of Otago, Christchurch, New Zealand.
Int J Clin Pract. 2016 Mar;70(3):261-76. doi: 10.1111/ijcp.12780.
The majority of older people with chronic diseases are prescribed multiple medicines resulting in polypharmacy. The extrapolation of the 'single disease model' represented by disease-specific guidelines is a major driver for polypharmacy. Polypharmacy is associated with negative health outcomes. Safely reducing or discontinuing harmful medicines, commonly referred to as deprescribing, has been shown to reduce adverse health outcomes, healthcare costs and mortality. However, there are barriers to deprescribing such as time constraints, limited appropriate clinical resources and the influence of multiple prescribers.
To explore general practitioners' (GPs') opinions and awareness of deprescribing in an older multimorbid patient.
A qualitative study design using face-to-face semi-structured interviews was implemented. GP practices were randomly selected from two cities in New Zealand. Face-to-face in depth interviews were carried out with participants. A hypothetical profile of a multimorbid patient was included to elicit discussions about whether medicines should be continued or discontinued. Interviews were transcribed verbatim for thematic analysis. Transcripts were read and re-read. Themes were identified with iterative building of a coding list until all data were accounted for. Interviews continued until saturation of ideas occurred.
Forty GPs were contacted and 10 consented to participate. Responses to each medicine in the hypothetical patient profile varied. Opinions on deprescribing preventive and symptomatic medicines varied a great deal. Conflicting opinions existed particularly around the prescription of statins, dipyridamole and bisphosphonates. Dilemmas around the appropriate clinical management of reflux disease and insomnia in older people also came to light.
Gaining an insight into GPs' current prescribing patterns is important in designing any interventions aimed at reducing inappropriate prescribing. This study highlights the lack of clarity around deprescribing in multimorbidity. The participants' individual responses varied considerably. Deprescribing guidelines may help to clarify evidence based medicine relating to controversial areas and could hence decrease this variation.
大多数患有慢性病的老年人会被开具多种药物，从而导致多重用药。以疾病特异性指南为代表的“单一疾病模式”的外推是多重用药的主要驱动因素。多重用药与不良健康结果相关。安全地减少或停用有害药物，通常称为减药，已被证明可以减少不良健康结果、医疗成本和死亡率。然而，减药存在障碍，如时间限制、适当临床资源有限以及多个开处方者的影响。
探讨全科医生（GP）对老年多病患者减药的看法和认识。
采用面对面半结构化访谈的定性研究设计。从新西兰的两个城市随机选择全科医生诊所。对参与者进行面对面深入访谈。纳入一个多病患者的假设概况，以引发关于药物应继续使用还是停用的讨论。访谈逐字转录以进行主题分析。转录本被反复阅读。通过迭代构建编码列表来确定主题，直到所有数据都得到解释。访谈持续进行，直到出现观点饱和。
联系了40名全科医生，10名同意参与。对假设患者概况中每种药物的反应各不相同。对预防性和对症性药物减药的看法差异很大。特别是在他汀类药物、双嘧达莫和双膦酸盐的处方方面存在相互矛盾的意见。老年人反流性疾病和失眠的适当临床管理方面的困境也凸显出来。
深入了解全科医生目前的处方模式对于设计任何旨在减少不适当处方的干预措施很重要。本研究突出了在多病共存情况下减药缺乏明确性。参与者的个人反应差异很大。减药指南可能有助于澄清与有争议领域相关的循证医学，从而减少这种差异。
