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Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids

INTRODUCTION: Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and...

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Autores principales: Parikh, Toral J., Stryczek, Krysttel C., Gillespie, Chris, Sayre, George G., Feemster, Laura, Udris, Edmunds, Majerczyk, Barbara, Rinne, Seppo T., Wiener, Renda Soylemez, Au, David H., Helfrich, Christian D.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498097/
https://www.ncbi.nlm.nih.gov/pubmed/32941462
http://dx.doi.org/10.1371/journal.pone.0238511
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author Parikh, Toral J.
Stryczek, Krysttel C.
Gillespie, Chris
Sayre, George G.
Feemster, Laura
Udris, Edmunds
Majerczyk, Barbara
Rinne, Seppo T.
Wiener, Renda Soylemez
Au, David H.
Helfrich, Christian D.
author_facet Parikh, Toral J.
Stryczek, Krysttel C.
Gillespie, Chris
Sayre, George G.
Feemster, Laura
Udris, Edmunds
Majerczyk, Barbara
Rinne, Seppo T.
Wiener, Renda Soylemez
Au, David H.
Helfrich, Christian D.
author_sort Parikh, Toral J.
collection PubMed
description INTRODUCTION: Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). METHODS: We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). RESULTS: The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient’s fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a ‘security blanket’. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. CONCLUSIONS: While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.
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spelling pubmed-74980972020-09-24 Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids Parikh, Toral J. Stryczek, Krysttel C. Gillespie, Chris Sayre, George G. Feemster, Laura Udris, Edmunds Majerczyk, Barbara Rinne, Seppo T. Wiener, Renda Soylemez Au, David H. Helfrich, Christian D. PLoS One Research Article INTRODUCTION: Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). METHODS: We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). RESULTS: The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient’s fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a ‘security blanket’. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. CONCLUSIONS: While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change. Public Library of Science 2020-09-17 /pmc/articles/PMC7498097/ /pubmed/32941462 http://dx.doi.org/10.1371/journal.pone.0238511 Text en https://creativecommons.org/publicdomain/zero/1.0/ This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 (https://creativecommons.org/publicdomain/zero/1.0/) public domain dedication.
spellingShingle Research Article
Parikh, Toral J.
Stryczek, Krysttel C.
Gillespie, Chris
Sayre, George G.
Feemster, Laura
Udris, Edmunds
Majerczyk, Barbara
Rinne, Seppo T.
Wiener, Renda Soylemez
Au, David H.
Helfrich, Christian D.
Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
title Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
title_full Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
title_fullStr Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
title_full_unstemmed Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
title_short Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
title_sort provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498097/
https://www.ncbi.nlm.nih.gov/pubmed/32941462
http://dx.doi.org/10.1371/journal.pone.0238511
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