Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis

Abstract

Background: Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics.

Methods: We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020.

Results: We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits).

Conclusions: Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.

Graphical abstract

Figure 1

The deprescribing process. A schematic of the deprescribing process provided during clinician focus groups and interviews. Adapted from ref. , with permission. PIMs, potentially inappropriate medications.

Figure 2

Patient responses from Patients' Attitudes towards Deprescribing questionnaire. This is a bar graph of participant responses to items included in the revised Patients' Attitudes towards Deprescribing questionnaire. Participants could choose one or none of “Strongly disagree” (1), “Disagree” (2), “Unsure” (3), “Agree” (4), “Strongly agree” (5). Shown here are combined responses for agree/strongly agree and disagree/strongly disagree. N=23 for all items.