Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States of America.
Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, United States of America.
PLoS One. 2020 Sep 17;15(9):e0238511. doi: 10.1371/journal.pone.0238511. eCollection 2020.
Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD).
We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%).
The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient's fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a 'security blanket'. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication.
While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.
尽管有证据表明可能对患者造成伤害和巨大的成本，但药物过度使用仍然存在。患者的反应是停止用药的一个潜在障碍，但很少有研究具体评估过停药时的这种反应。我们试图了解退伍军人和医务人员在实施与指南不符的治疗方案时，即停止使用吸入性皮质类固醇（ICS）治疗轻中度慢性阻塞性肺疾病（COPD）患者时的经验。
我们在一项针对提供者的随机质量改进项目中进行了一项混合方法分析，该项目测试了肺病专家主动进行电子咨询，建议在适当的情况下停止使用 ICS。研究对象包括两个退伍军人健康管理局医疗系统的初级保健医生（PCP）。我们对 16 名未暴露于该方案的提供者和 6 名干预组暴露于该方案的提供者进行了访谈。在 PCP 提出停止 ICS 治疗后 3 个月内，我们对 9 名患者进行了访谈。我们对定性数据进行了归纳和演绎内容分析，以探索患者反应这一新兴主题。共有 48 名 PCP （暴露组 24 名，未暴露组 24 名，回复率：35%）返回了调查问卷。
未暴露于该方案的提供者预计他们的患者可能会抵制停止使用 ICS，因为停止使用正在起作用的药物似乎违背直觉，或者因为患者担心症状恶化，或者处方是由其他医生开具的。干预组暴露于该方案的提供者在干预后的访谈中报告了类似的经历。未暴露于该方案的提供者预计患者可能会接受停止使用 ICS，理由是他们采用了以患者为中心的策略。干预组暴露于该方案的提供者也表示同意，他们成功地停止了 ICS 的使用。退伍军人表示，出于对提供者的信任或对其高级培训的尊重，即使他们将 ICS 描述为“安全毯”，他们也会听从提供者的建议。我们的调查结果支持了我们访谈中的子主题。在提出停止使用 ICS 的 PCP 中，有 76%的人报告说他们能够停止使用 ICS 或改用另一种更合适的药物。
尽管 PCP 预计患者会抵制停止使用 ICS，但对患者和干预组暴露于该方案的 PCP 的访谈以及调查结果表明，患者对这一变化持接受态度。
