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Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults
Parag Goyal1, Timothy S Anderson2, Gwen M Bernacki3,4
1Department of Medicine, Weill Cornell Medicine, New York, New York.
Insights
Deprescribing cardiovascular medications is considered by most clinicians, with adverse drug reactions being a common reason. However, reasons for deprescribing, particularly in limited life expectancy, vary by specialty.
Area of Science:
- Geriatric Medicine
- Cardiology
- Internal Medicine
- Pharmacology
Background:
- Cardiovascular disease management often leads to polypharmacy in older adults, increasing adverse drug event risks.
- Deprescribing cardiovascular medications is a strategy to mitigate these risks.
- Clinician perspectives on deprescribing cardiovascular medications across specialties are not well characterized.
Purpose of the Study:
- To characterize and compare clinician perspectives on deprescribing cardiovascular medications.
- To identify reasons for and barriers to deprescribing.
- To examine medication deprescribing choices in hypothetical clinical scenarios.
Main Methods:
- A national cross-sectional survey was conducted.
- Participants included a random sample of geriatricians, general internists, and cardiologists.
- The survey assessed deprescribing practices, reasons, barriers, and choices in clinical cases.
Main Results:
- Over 80% of surveyed physicians considered deprescribing cardiovascular medications, with adverse drug reactions being the most common reason.
- Barriers included concerns about interfering with other physicians' plans and patient reluctance.
- Geriatricians were more likely than cardiologists to consider deprescribing in cases of limited life expectancy.
Conclusions:
- Shared barriers exist for deprescribing cardiovascular medications across specialties.
- Reasons for deprescribing, especially for patients with limited life expectancy, differ among geriatricians, general internists, and cardiologists.
- Improved physician-physician and physician-patient communication is essential for implementing deprescribing.
Background/Objectives:
Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.
Design:
National cross-sectional survey.
Setting:
Ambulatory.
Participants:
Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians.
Measurements:
Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.
Results:
In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists).
Conclusions:
While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.
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