Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults

Parag Goyal, MD, MSc; Timothy S. Anderson, MD, MAS, MA; Gwen M. Bernacki, MD, MHSA; Zachary A. Marcum, PharmD, PhD; Ariela R. Orkaby, MD, MPH; Dae Kim, MD, MPH, ScD; Andrew Zullo, PharmD, PhD; Ashok Krishnaswami, MD, MAS; Arlene Weissman, PhD; Michael A. Steinman, MD; Michael W. Rich, MD

Disclosures

J Am Geriatr Soc. 2020;68(1):78-86. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

Cardiovascular medications, such as antiplatelet, antihypertensive, and lipid-lowering agents, are among the most commonly prescribed medication classes in the United States.[1] While the benefits of these medications for reducing primary and secondary cardiovascular events are well established and they are recommended in clinical practice guidelines, they have also contributed to rising rates of polypharmacy and adverse drug events in older adults.[2] As adults age, many develop multiple chronic conditions and impairments in core domains, such as function and cognition. As a result, the risk-benefit profile of cardiovascular medications can change, whereby risks may increase and benefits may decrease.[3] Moreover, some cardiovascular medications may not provide any additional value to older adults in select contexts.[4,5] Deprescribing has emerged as a strategy to optimize medication prescribing practice through the discontinuation of agents for which the risks outweigh the benefits in the context of an individual's care goals, level of functioning, life expectancy, values, and preferences.[6] Deprescribing has been shown to reduce polypharmacy and medication-related adverse events[7] and, thus, may be particularly applicable to improving cardiovascular medication prescribing practice for older adults.

Although deprescribing has attracted increased attention over the last few years,[8] the real-world practice of deprescribing cardiovascular medications is not well characterized. Physicians report multiple barriers to deprescribing, including lack of awareness, lack of self-efficacy, clinical inertia, and the perception that patients are reluctant to stop medications;[9–13] however, prior literature has primarily examined potentially inappropriate medications (PIMs) for which high levels of risk outweigh low potential for benefit in many older adults.[14,15] The risk-benefit ratio for cardiovascular medications may seem less clear to clinicians, and it frequently depends on the context of the individual older adults' health. Prior studies have focused on primary care physicians' perspectives on deprescribing.[9,10,12] Accordingly, there are important gaps in our knowledge regarding differences in perspectives on deprescribing cardiovascular medications across three specialties that often provide care to older adults.

Understanding specialty-based differences in deprescribing practice and attitudes is important as older adults are frequently comanaged by a geriatrician or a general internist and a cardiologist.[16] Identifying discordance between specialties has implications on the use of deprescribing, as disagreements between clinicians could undermine effective implementation. Therefore, we sought to determine how frequently physicians from different specialties reported deprescribing cardiovascular medications in their clinical practice, to identify reasons for and barriers to deprescribing, and to compare medication deprescribing priorities across disciplines. To meet this objective, we surveyed a national sample of geriatricians, general internists, and cardiologists from the American College of Physicians (ACP) membership list.

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