Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study.

BACKGROUND: Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians' baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians' (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios. METHODS: As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients' expectations surrounding low-value prescribing. RESULTS: We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients' well-being over satisfying their expectations. CONCLUSIONS: When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Experiences of American Older Adults with Pre-existing Depression During the Beginnings of the COVID-19 Pandemic: A Multicity, Mixed-Methods Study.

OBJECTIVE: To determine the effect of the COVID-19 pandemic on the mental health of older adults with pre-existing major depressive disorder (MDD). PARTICIPANTS: Participants were 73 community-living older adults with pre-existing MDD (mean age 69 [SD 6]) in Los Angeles, New York, Pittsburgh, and St Louis. DESIGN AND MEASUREMENTS: During the first 2 months of the pandemic, the authors interviewed participants with a semistructured qualitative interview evaluating access to care, mental health, quality of life, and coping. The authors also assessed depression, anxiety, and suicidality with validated scales and compared scores before and during the pandemic. RESULTS: Five themes from the interviews highlight the experience of older adults with MDD: 1) They are more concerned about the risk of contracting the virus than the risks of isolation. 2) They exhibit resilience to the stress and isolation of physical distancing. 3) Most are not isolated socially, with virtual contact with friends and family. 4) Their quality of life is lower, and they worry their mental health will suffer with continued physical distancing. 5) They are outraged by an inadequate governmental response to the pandemic. Depression, anxiety, and suicidal ideation symptom scores did not differ from scores before the pandemic. CONCLUSION: Most older adults with pre-existing MDD show resilience in the first 2 months of the COVID-19 pandemic but have concerns about the future. Policies and interventions to provide access to medical services and opportunities for social interaction are needed to help to maintain mental health and quality of life as the pandemic continues.

Factors Related to the Rise of Congenital Syphilis From the Perspectives of Prenatal Providers and Birthing Parents in Chicago, IL, USA.

Background: Rates of congenital syphilis (CS) in the United States have risen sharply in recent years. There has been sparse research centering the voices and experiences of birthing parents who have delivered infants with CS and prenatal providers in Chicago or the surrounding Midwestern United States to date. Additionally, there has been little research on the role of extrinsic factors, such as stigma and attitudes surrounding CS in an individual's community, in their entry into and retention in the CS prevention cascade. Methods: Semistructured interviews seeking to gather perspectives and factors related to the rise of CS were conducted with birthing parents who delivered infants with CS at a major academic medical institution (AMI) and the prenatal providers who served them. This was supplemented by retrospective data of birthing parent outcomes. Results: Barriers elicited during the interviews included insufficient penicillin uptake, limited transportation, poor communication between providers and patients, gaps in patient understanding or knowledge around CS contraction and treatment, missed appointments, appointment burden for patients, life stressors of patients, housing instability, childcare difficulties, and stigma related to the CS diagnosis. The quantitative data revealed differing proportions of CS outcomes and care between those with care within the AMI, those with care outside the AMI, and those who had no prenatal care. Conclusions: This study found numerous perspectives and factors that may explain the rise of CS along various stages of the syphilis care continuum through in-depth interviews of prenatal providers and birthing parents.

Increasing providers' PrEP prescription for Black cisgender women: A qualitative study to improve provider knowledge and competency via PrEP training.

BACKGROUND: Awareness and uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) remains low among Black/African American cisgender women, partly due to low self-reported PrEP knowledge and comfort among primary care providers. Ensuring providers are trained on PrEP is crucial, as increased PrEP knowledge is associated with higher rates of PrEP prescription. OBJECTIVE: We aimed to develop a PrEP training for providers to improve their self-efficacy in discussing and prescribing PrEP for Black women, with the ultimate goal of increasing PrEP awareness and utilization among Black women. DESIGN: In this qualitative study, we conducted focus groups with medical providers at three federally qualified health centers in the Southern and Midwestern United States to identify themes informing the development of a provider PrEP training. METHODS: Providers were asked for input on content/design of PrEP training. Transcripts underwent rapid qualitative analysis using the Stanford Lightning Report Method. Themes were identified and presented under the domains of the Consolidated Framework for Implementation Research. RESULTS: Ten providers completed four focus groups. Themes included the individual characteristics of providers (low comfort initiating PrEP discussions, particularly among White providers) and the outer setting of client attitudes (perceptions of potential provider bias/racism, varying levels of concern about HIV acquisition). Opportunities were identified to maximize the benefit of training design (e.g., developing case scenarios to enhance providers' cultural competency with Black women and PrEP knowledge). CONCLUSION: This comprehensive PrEP training features both didactic material and interactive role-plays to equip providers with the clinical knowledge for prescribing PrEP while building their competency discussing PrEP with Black women. This training is particularly important for providers who have racial or gender discordance with Black women and express lower comfort discussing PrEP with these clients. Provider training could lead to minimizing racial- and gender-based inequities in PrEP use.

Increasing the use of pre-exposure prophylaxis (PrEP) among Black women: a study to improve provider knowledge through PrEP trainingWhy was the study done? Use of pre-exposure prophylaxis (PrEP), a medication that can prevent the transmission of human immunodeficiency virus (HIV), is low among Black/African American women. Part of the reason why is because primary care providers (PCPs) report lower knowledge about PrEP and lower comfort talking about PrEP with clients. Making sure PCPs are trained on PrEP could help increase PrEP use among Black women. What did the researchers do? The research team held focus groups, during which they asked medical providers at federally qualified health centers (FQHCs) in the Southern and Midwestern United States questions about their experiences with discussing PrEP and what information should be included in a training about PrEP for providers to make sure the training would be helpful for them. What did the researchers find? A total of ten providers completed four focus groups. Important points mentioned in the focus groups included low comfort among providers when bringing up PrEP to clients, especially among White providers, as well as different levels of concern about HIV and feelings of potential provider bias/racism among clients. These points helped the researchers design a PrEP training that addresses providers' needs (such as creating case scenarios that help providers practice discussing PrEP with Black women and answering common questions about PrEP). What do the findings mean? A PrEP training for providers should have both information about prescribing PrEP and interactive role-plays to build providers' PrEP knowledge while improving their confidence and skill in talking about PrEP with Black women. This training is particularly important for providers who are a different race or gender than Black women and express lower rates of comfort discussing PrEP with these clients. Provider training could eventually lead to higher PrEP use among Black women.

Adapting Provider Training and Pre-Exposure Prophylaxis Advertising to Increase Pre-Exposure Prophylaxis Awareness and Uptake Among Black Cisgender Women.

Black cisgender women (hereafter referred to as "women") have disproportionately high rates of HIV infection yet low rates of pre-exposure prophylaxis (PrEP) utilization. Barriers to PrEP uptake exist at the system, provider, and individual/client level. To learn how existing training and advertising can be adapted to address race- and sex-based gaps within PrEP service delivery, we conducted focus groups with providers and Black women. Participants were recruited at three health care organizations in the Midwest and South, screened for eligibility, and consented verbally. Focus groups occurred from August 2022 to February 2023. Women were asked about their knowledge and thoughts on PrEP. Providers were asked about factors influencing their decision-making about PrEP. A codebook was developed based on the Consolidated Framework for Implementation Research. Transcripts were coded using the Stanford Lightning Report Method. We completed four focus groups with 10 providers and 9 focus groups with 25 women. Three major themes emerged: (1) low comfort level and limited cultural sensitivity/competency among providers discussing HIV risk and PrEP with Black women, (2) women's concerns about PrEP's side effects and safety during pregnancy, and (3) lack of Black women representation in PrEP advertisement/educational materials. In addition, women in the South reported general medical mistrust and specific misconceptions about PrEP. PrEP trainings for providers need detailed information about the safety of PrEP for women and should include role-playing to enhance cultural competency. Likewise, PrEP advertisements/materials should incorporate information regarding side effects and images/experiences of Black women to increase PrEP awareness and uptake among this population. Clinical Trial Registration Number: NCT05626452.

"What else can we do?"-Provider perspectives on treatment-resistant depression in late life.

BACKGROUND: Treatment-resistant depression in late-life (TRLLD) is common. Perspectives of primary care providers (PCPs) and psychiatrists treating TRLLD could give insights into the challenges and potential solutions for managing this condition. METHODS: To identify perspectives of providers who treat TRLLD, we conducted a qualitative descriptive study using semi-structured interviews with providers treating older adults with TRLLD in five locations across North America (i.e., Los Angeles, New York City, Pittsburgh, St. Louis, and Toronto). We conducted semi-structured interviews with 50 care providers (24 primary care providers [PCPs], 22 psychiatrists, and 4 depression care managers). Interviews elicited providers' perspectives on treatment options for TRLLD, including treatment within the primary care setting and referral to psychiatry, and sought suggestions for improvement. RESULTS: We identified four themes. (1) Treating TRLLD takes an emotional toll on providers; (2) existing psychiatric services are inadequate to meet the needs of patients with TRLLD, mainly because of lack of access; (3) PCPs often attempt to treat TRLLD, even when they are not comfortable doing so; and (4) to better meet the needs of patients with TRLLD, providers recommend integrated care models involving PCPs, psychiatrists, and psychotherapists, potentially made more feasible by the growth of telehealth. CONCLUSIONS: Findings from these qualitative interviews show the challenges in providing care for TRLLD. These findings can guide knowledge dissemination to psychiatrists, PCPs, policy-makers, and other stakeholders involved in the mental health system. They can also inform structural changes to clinical practice that may increase the implementation of the best treatment strategies across settings to improve long-term outcomes for TRLLD.

This Is a Different Patient Population: Opioid Prescribing Challenges for Patients With Cancer-Related Pain.

PURPOSE: Responses to the opioid epidemic in the United States, including efforts to monitor and limit prescriptions for noncancer pain, may be affecting patients with cancer. Oncologists' views on how the opioid epidemic may be influencing treatment of cancer-related pain are not well understood. METHODS: We conducted a multisite qualitative interview study with 26 oncologists from a mix of urban and rural practices in Western Pennsylvania. The interview guide asked about oncologists' views of and experiences in treating cancer-related pain in the context of the opioid epidemic. A multidisciplinary team conducted thematic analysis of interview transcripts to identify and refine themes related to challenges to safe and effective opioid prescribing for cancer-related pain and recommendations for improvement. RESULTS: Oncologists described three main challenges: (1) patients who receive opioids for cancer-related pain feel stigmatized by clinicians, pharmacists, and society; (2) patients with cancer-related pain fear becoming addicted, which affects their willingness to accept prescription opioids; and (3) guidelines for safe and effective opioid prescribing are often misinterpreted, leading to access issues. Suggested improvements included educational materials for patients and families, efforts to better inform prescribers and the public about safe and appropriate uses of opioids for cancer-related pain, and additional support from pain and/or palliative care specialists. CONCLUSION: Challenges to safe and effective opioid prescribing for cancer-related pain include opioid stigma and access barriers. Interventions that address opioid stigma and provide additional resources for clinicians navigating complex opioid prescribing guidelines may help to optimize cancer pain treatment.

Prescriber perspectives on low-value prescribing: A qualitative study.

BACKGROUND: Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. OBJECTIVE: To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. DESIGN: Qualitative study using semi-structured interviews. SETTING: Academic and community primary care practices within University of Pittsburgh Medical Center health system. PARTICIPANTS: Sixteen primary care physicians. MEASUREMENTS: We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing. RESULTS: We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. CONCLUSIONS: Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study.

OBJECTIVES: Shared decision making is essential to deprescribing unnecessary or harmful medications in older adults, yet patients' and caregivers' perspectives on medication value and how this affects their willingness to discontinue a medication are poorly understood. We sought to identify the most significant factors that impact the perceived value of a medication from the perspective of patients and caregivers. DESIGN: Qualitative study using focus groups conducted in September and October 2018. SETTING: Participants from the Pepper Geriatric Research Registry (patients) and the Pitt+Me Registry (caregivers) maintained by the University of Pittsburgh. PARTICIPANTS: Six focus groups of community-dwelling adults aged 65 years or older, or their caregivers, prescribed five or more medications in the preceding 12 months. MEASUREMENTS: We sought to identify (1) general views on medication value and what makes medication worth taking; (2) how specific features such as cost or side effects impact perceived value; and (3) reactions to clinical scenarios related to deprescribing. RESULTS: We identified four themes. Perceived effectiveness was the primary factor that caused participants to consider a medication to be of high value. Participants considered a medication to be of low value if it adversely affected quality of life. Participants also cited cost when determining value, especially if it resulted in material sacrifices. Participants valued medications prescribed by providers with whom they had good relationships rather than valuing level of training. When presented with clinical scenarios, participants ably weighed these factors when determining the value of a medication and indicated whether they would adhere to a deprescribing recommendation. CONCLUSION: We identified that perceived effectiveness, adverse effects on quality of life, cost, and a strong relationship with the prescriber influenced patients' and caregivers' views on medication value. These findings will enable prescribers to engage older patients in shared decision making when deprescribing unnecessary medications and will allow health systems to incorporate patient-centered assessment of value into systems-based deprescribing interventions. J Am Geriatr Soc 68:746-753, 2020.