Factors influencing deprescribing in primary care for those towards the end of life: A qualitative interview study with patients and healthcare practitioners.

BACKGROUND: For people with limited lifetime expectancy, the benefit of many medications may be outweighed by their potential harms. Despite the relevance of reducing unnecessary medication use, deprescribing is poorly enacted in primary care practice. AIM: This study aims to describe factors, as identified by primary care professionals and patients, that influence deprescribing in the last phase of life. DESIGN: Semi-structured interviews were conducted and analysed using a thematic approach. SETTING/PARTICIPANTS: This study was performed in primary care settings, including general practices, hospices and community care teams in The Netherlands. Purposefully identified primary care professionals (general practitioners, pharmacists, nurses) and patients with limited lifetime expectancy due to advanced chronic illness or cancer and their caretakers were interviewed. RESULTS: Three themes emerged detailing factors influencing deprescribing in the last phase of life in primary care: (1) non-maleficence, the wish to avoid additional psychological or physical distress; (2) reactive care, the lack of priority and awareness of eligible patients; and (3) discontinuity of care within primary care and between primary care and specialty care. CONCLUSIONS: Deprescribing is an incremental process, complicated by the unpredictability of life expectancy and attitudes of patients and health care professionals that associate continued medication use with clinical stability. Opportunities to facilitate the deprescribing process and its acceptance include the routinely systematic identification of patients with limited life expectancy and potentially inappropriate medications, and normalisation of deprescribing as component of regular primary care, occurring for all patients and continuing into end-of-life care.

Routine primary care data for scientific research, quality of care programs and educational purposes: the Julius General Practitioners' Network (JGPN).

BACKGROUND: General Practitioners (GPs) in the Netherlands routinely register all patient contacts electronically. These records include longitudinally gathered clinical information of the patient contacts in coded data and free text. METHODS: Diagnoses are coded according to the International Coding of Primary Care (ICPC). Drug prescriptions are labelled with the Anatomical Therapeutic Chemical Classification (ATC), and letters of hospital specialists and paramedic health care professionals are linked or directly incorporated in the electronic medical files. A network of a large group of GPs collecting routine care data on an ongoing basis can be used for answering various research questions. RESULTS: The Julius General Practitioners' Network (JGPN) database consists of routine care data from over ten years of a dynamic cohort of around 370,000 individuals registered with the participating GPs from the city of Utrecht and its vicinity. Health care data are extracted anonymously every quartile of a year and these data are used by researchers. CONCLUSION: We describe the content and usability of our JGPN database, and how a wide variety of research questions could be answered, as illustrated with examples of published articles.

Use of preventive medication and supplements in general practice in patients in their last year of life: a Retrospective cohort study.

BACKGROUND: Several preventive medications and supplements become inappropriate in the last phase of life due to increased risk of adverse events caused by changed pharmacokinetics, drug-drug interactions, and changed care goals. Information on these preventive medication and supplements use in patients with a life-limiting illness in the home-care setting is limited. The primary aim of this study was to assess the use of four different groups of preventive drugs and supplements, which are inappropriate in adult patients with a life-limiting illness, living at home in the last year of life. The secondary aims were to assess reasons for discontinuing these drugs as documented in the general practitioners' patient file and whether these reasons affected the time between medication discontinuation and death. METHODS: We performed a retrospective cohort study using the routine primary care database of the Julius General Practitioners' Network of the University Medical Centre Utrecht, a database consisting of routine care data from GPs from the city of Utrecht and its vicinity. Patients in the homecare setting with a life-limiting illness, diagnosed at least one year before death, were included. Descriptive analyses were used to describe the study population and the frequency of starting, using, and discontinuing medication and supplements in the last year of life. RESULTS: A total of 458 of 666 included patients (69%) used at least one preventive drug in the last year of life. Vitamins were used by 36% of the patients, followed with 35% using cholesterol-lowering medication, 24% using calcium supplements and 9% using bisphosphonates. Bisphosphonates were discontinued by 70% of the users, calcium supplements by 61%, vitamins by 56% and cholesterol-lowering medication by 48% of the users, with a median interval between day of discontinuation and death of 119, 60, 110 and, 65 days, respectively. The median time between medication or supplement discontinuation and death was longest in patients with side effects and who had medication reviews. CONCLUSION: Many patients in their last phase of life in the home-care setting use inappropriate medication and supplements. Timely medication review may contribute to optimise medication use in the last year of life.

Needs, barriers and facilitators of older adults towards eHealth in general practice: a qualitative study.

BACKGROUND: The strain on health care services is increasing due to an ageing population and the increasing prevalence of chronic health conditions. eHealth could contribute to optimise effective and efficient care to older adults with one or more chronic health conditions in the general practice. AIM: The aim of this study was to identify the needs, barriers and facilitators amongst community-dwelling older adults (60+) suffering from one or more chronic health conditions, in using online eHealth applications to support general practice services. METHODS: A qualitative study, using semi-structured followed by think-aloud interviews, was conducted in the Netherlands. The semi-structured interviews, supported by an interview guide were conducted and analysed thematically. The think-aloud method was used to collect data about the cognitive process while the participant was completing a task within online eHealth applications. Verbal analysis according to the Chi approach was conducted to analyse the think-aloud interviews. FINDINGS: A total of n = 19 older adults with a mean age of 73 years participated. The ability to have immediate contact with the GP on important health issues was identified as an important need. Identified barriers were non-familiarity with the online eHealth applications and a mismatch of user health needs. The low computer experience resulted in non-familiarity with the online eHealth applications. Faltering applications resulted in participants refusing to participate in the use of online eHealth applications. Convenience, efficiency and the instant availability of eHealth via applications were identified as important facilitators. CONCLUSION: To improve the use and acceptability of eHealth applications amongst older adults in the general practice, the applications should be tailored to meet individual needs. More attention should be given to improving the user-friendliness of these applications and to the promotion of the benefits such as facilitating older adults independent living for longer.