Association Between Willingness to Deprescribe and Health Outcome Priorities Among U.S. Older Adults

Results of a National Survey

Ariel R. Green MD, MPH, PhD; Hélène Aschmann PhD; Cynthia M. Boyd MD, MPH; Nancy Schoenborn MD, MHS

Disclosures

J Am Geriatr Soc. 2022;70(10):2895-2904. 

In This Article

Abstract and Introduction

Abstract

Background: It is not known whether older adults' willingness to deprescribe is associated with their health outcome priorities related to medications.

Methods: A cross-sectional survey was conducted from March–April 2020 using a nationally representative online panel. The survey presented two vignettes: (1) a preventive medicine; and (2) a symptom-relief medicine. Participants were asked whether they would be willing to stop each medicine if their doctor recommended it, and to rate their level of agreement with two health outcome priorities statements: "I am willing to accept the risk of future side effects … to feel better now," and "I would prefer to take fewer medicines, even if … I may not live as long or may have bothersome symptoms sometimes." Ordinal logistic regression was used to examine associations between willingness to stop each medicine, baseline characteristics and health outcome priorities.

Results: Of 1193 panel members ≥65 years invited to participate, 835 (70%) completed the survey. Mean (SD) age was 73 years; 496 (59%) had taken a statin and 124 (15%) a prescription sedative-hypnotic. 507 (61%) were willing to stop preventive medicines; 276 (33%) were maybe willing. 419 (50%) were willing to stop symptom-relief medicines; 380 (46%) were maybe willing. Prioritizing fewer medicines was associated with higher odds of being willing to stop symptom-relief medicines (aOR 1.43 [95% CI 1.02–2.00]) and preventive medicines (aOR 1.52 [95% CI 1.05–2.18]). Prioritizing now over future was associated with lower odds of being willing to stop symptom-relief medicines (aOR 0.62 [95% CI 0.39–1.00]). Current/prior use of statins was associated with lower willingness to stop preventive medicines (aOR 0.66 [95% CI 0.48–0.91]).

Conclusions: Older adults' health outcome priorities related to medication use are associated with their willingness to consider deprescribing. Future research should determine how best to elicit patients' health outcome priorities to facilitate goal-concordant decisions about medication use.

Introduction

In the United States, 36% of patients aged 65 or older use at least five prescription medicines concurrently.[1] Polypharmacy is associated with high risk of drug interactions, treatment burden, and adverse drug events—including hospitalization, disability, negative effects on cognitive function, and death.[2–5] Approximately one in five drugs commonly used in older people may be inappropriate,[6] meaning that the potential harms outweigh the expected clinical benefits or that safer alternatives are available.[7]

Deprescribing is the physician-supervised process of reducing or stopping a medication that is inappropriate or no longer necessary, with the goal of improving health and quality-of-life outcomes.[8,9] Deprescribing is a promising strategy to reduce high rates of iatrogenic harm for older adults with multiple chronic conditions. Most older adults in the United States are open to deprescribing, with 92% of Medicare beneficiaries in a national survey reporting that they would be willing to deprescribe if their physician said it was possible, and 66% wanting to reduce the number of medicines that they were taking.[10] Yet in spite of these findings, uptake of deprescribing in the United States remains suboptimal. How clinicians communicate about deprescribing may affect to what extent older adults are willing to do it. Deprescribing, including the determination of whether a given medication is suitable for withdrawal, should occur within the framework of shared decision making between patient and clinician.[8]

An important part of shared decision making is the integration of older adults' health outcome priorities—the health outcome goals a person most desires in the context of what they are willing and able to do to achieve those outcomes.[11] A small body of literature has explored how older adults consider competing priorities in healthcare decision making (e.g., are they willing to compromise on stroke risk reduction to avoid falls when medications that lower stroke risk, such as anti-hypertensives, are linked to increased fall risk),[12–14] but it is not known how these perspectives may translate to willingness to deprescribe a medication that they are already taking, particularly a symptom-relief medication. Studies have suggested that incorporating older adults' health outcome goals and priorities into clinical decision making may be associated with reductions in unwanted healthcare and treatment burden.[15–17] For these reasons, we sought to investigate whether patients' health outcome priorities related to medication use are associated with their willingness to consider deprescribing.

This study used a national survey to investigate two objectives. First, we characterized older adults' health outcome priorities related to medication use and how these varied by individual characteristics. Second, we examined associations between willingness to deprescribe two types of medications (preventive and symptom-relief), individual health outcome priorities related to medication use, and other individual characteristics, in order to determine whether incorporating health outcome priorities into deprescribing communication may be a promising strategy to enhance uptake of deprescribing.

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