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

Results

Among an overall sample of 2250 ACP members, 572 (25%) completed the survey. Among respondents, 119 were excluded for the following reasons: 67 were not clinically active, 29 did not provide ambulatory care, 8 were trainees, and 15 practiced other specialties. This resulted in an overall response rate of 21% (453/2131). The response rate was 26% for geriatricians, 26% for general internists, and 12% for cardiologists (P < .001). Respondents did not differ in age or sex from the sample surveyed; however, respondents were significantly more likely to have graduated from a US medical school (Supplementary Table S1).

Table 1 shows respondent characteristics. All census regions were well represented. Most respondents had at least 20 years of clinical experience, and most spent over 75% of their time providing patient care. A third of respondents practiced in an academic-affiliated setting. A smaller proportion of cardiologist respondents were female and reported working exclusively in the outpatient setting compared to other specialties.

Consideration of Deprescribing

Over 80% of respondents within each specialty reported that they had considered deprescribing a cardiovascular medication in the prior month (Figure 1A). Among all specialties, the most common reason to consider deprescribing was adverse drug reactions (Figure 1B). Low likelihood to confer benefit due to a limited life expectancy was a common reason to consider deprescribing in the prior month among geriatricians (73%) but was not common among general internists (37%) or cardiologists (14%). No other reasons to consider deprescribing exceeded 50% for any specialty. Among the less common reasons to consider deprescribing, geriatricians more frequently reported concerns about cognition (26% of geriatricians, 13% of general internists, and 9% of cardiologists; P < .001) and less frequently reported a lack of apparent indication (18% of geriatricians, 30% of general internists, and 30% of cardiologists; P = .025) and medication cost (7% of geriatricians, 21% of general internists, and 31% of cardiologists; P < .001) compared to other specialties.

Figure 1.

Deprescribing behavior, according to specialty. A, Percentage of respondents who considered deprescribing cardiovascular medications in the prior month. B, Reported reasons for considering deprescribing cardiovascular medications. *P < .05.

Discussing Deprescribing With Other Physicians

In the prior month, 55% of geriatricians, 38% of general internists, and 41% of cardiologists reported discussing deprescribing a cardiovascular medication with another clinician (P = .005) (Figure 2A). The most common reason for discussing deprescribing with another physician, irrespective of specialty, was adverse drug reactions (Figure 2B). Notably, geriatricians were more likely to report limited life expectancy as a reason for discussing deprescribing with another clinician compared to other specialties (73% of geriatricians, 37% of general internists, and 14% of cardiologists; P = .001).

Figure 2.

Physician-physician communication about deprescribing cardiovascular medications, according to specialty. A, Percentage of respondents who discussed deprescribing cardiovascular medications with another clinician in the prior month. B, Reported reasons for discussing deprescribing cardiovascular medications with another clinician. *P < .05.

Barriers to Deprescribing

The most common barriers to deprescribing cardiovascular medications were similar across specialties and included concern about interfering with other clinicians' treatment plans, patient reluctance for deprescribing, and lack of patient understanding of deprescribing (Figure 3). Other potential reasons, such as those related to time constraints, medicolegal concerns, insufficient evidence base, and limited training, were infrequently reported. Among the less commonly reported barriers to deprescribing, geriatricians were less likely to report insufficient evidence of deprescribing efforts as a barrier compared to other specialties (8% of geriatricians, 19% of general internists, and 24% of cardiologists; P < .001) and less likely to report limited formal training on deprescribing (2% of geriatricians, 16% of general internists, and 6% of cardiologists; P < .001) compared to other specialties.

Figure 3.

Reported barriers to deprescribing cardiovascular medications, according to specialty. *P < .05.

Case-based Deprescribing Practices

Table 2 shows medications that respondents would consider deprescribing in hypothetical scenarios involving a 79-year-old woman taking four cardiovascular medications. In the base case where the patient had no specific concerns, 41% of geriatricians, 25% of general internists, and 23% of cardiologists reported that they would consider deprescribing at least one cardiovascular medication. For scenarios in which the patient was symptomatic from a potential adverse drug reaction (lightheadedness with a recent fall, orthostatic symptoms, or hypotension), 92% to 99% of respondents from each specialty would consider deprescribing at least one cardiovascular medication. For scenarios related to a limited life expectancy, responses were more heterogeneous across specialties. Recent metastatic recurrence of breast cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists; P < .001), transfer to a skilled nursing facility with a new diagnosis of Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists; P < .001), and increased difficulty in activities of daily living (83% of geriatricians, 65% of general internists, and 49% of cardiologists; P < .001) were more commonly reported as reasons to consider deprescribing by geriatricians compared to other specialties. Notably, a higher proportion of cardiologists considered deprescribing for an asymptomatic 90-year-old patient compared to any of the other limited life expectancy scenarios.

There was substantial variation across the specialties regarding the medications that they would consider deprescribing (Table 2). Aspirin and statins were commonly considered for deprescribing among geriatricians in several scenarios, while they were infrequently considered for deprescribing among cardiologists. Cardiologists also less frequently considered deprescribing metoprolol in several scenarios compared to other specialties.

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